Category I: GPs’ views on antibiotic use, ABR, and the pathogenesis of ARTIs

Antibiotics were viewed as precious tools that must be used judiciously. GPs acknowledged that antibiotics should not be overprescribed but feared that delaying necessary antibiotic treatment could result in more complicated infections. Nevertheless, a “wait-and-see approach”, i.e., requesting patients call back or return for follow-up should they deteriorate, and delayed antibiotic prescription, were often perceived as good strategies to minimise antibiotic use, although seldom with the intention of limiting ABR.

“Antibiotics are obviously very important, very special and very precious drugs. Why? Because we are running out of them. … They are wonder drugs, you cure people, you save lives. We underestimate what we do because we’re continuously saving lives with them…” (GP-J; male private GP; 41 years’ experience).

GPs were aware that antibiotic misuse accelerates ABR, restricting treatment options if left uncontrolled. Many believed that ABR is on the rise in Malta because of antibiotic overuse and misuse (particularly for viral infections) by prescribers, pharmacists, and the public alike. GPs remarked that broad-spectrum antibiotics are overused and that patients self-medicate, are non-compliant, retain leftover antibiotics, and acquire antibiotics over the counter, although this practice has allegedly almost ceased following revision in prescription policies. Marketing of specific antibiotic classes by drug reps was also considered a driver.

“…in the community you can basically touch resistance. Often you prescribe something that used to work, and patients return saying it hasn’t worked.” (GP-I; male private GP; 39 years’ experience).

Few GPs opined that ABR directly impacted their practice. Rather, several GPs reported achieving good results when prescribing antibiotics although they noted that ABR forced them to prescribe more broad-spectrum antibiotics. GPs disagreed about antibiotic doses; some believed high doses are unnecessary, others favoured more aggressive antibiotic therapy to avoid resistance development. Seldom, GPs reported prescribing combination antibiotic therapy to ensure infection resolution or limit ABR development, although many believed this unnecessary.

Although GPs considered the majority (70–90%) of upper ARTIs to be viral, GPs found it difficult to determine their aetiology based on clinical presentation, particularly lower ARTIs. Some determined aetiology over time, typically waiting 2–5 days for an infection to resolve. GPs also often believed viral infections commonly progress to secondary bacterial infections, particularly in the elderly.

“There is a tendency for old, frail patients with viral infections to get secondary bacterial infections… It would be indicated that it is a viral infection but being an old patient, prescribing an antibiotic won’t do any harm.” (GP-A; male private GP; 30 years’ experience).

Infections non-responsive to antibiotic therapy were often believed to be antibiotic-resistant or progression from a viral infection to a secondary bacterial infection; few noted non-response could be due to antibiotics prescribed unnecessarily for a viral infection. Determining the cause of a non-responsive infection was perceived as challenging, particularly without local data, and sometimes resulted in the prescription of multiple antibiotic courses.

“It’s very difficult to know whether an infection is resistant or whether they are non-responsive to treatment because they never needed antibiotics in the first place.” (GP-B; female public GP; 25 years’ experience).

Category II: GPs’ self-reported antibiotic prescribing practices

Antibiotic prescribing was viewed by several GPs as their sole responsibility, however self-reported practices varied widely. GPs not in favour of prescribing antibiotics immediately often chose to delay antibiotic prescription, particularly in mild or suspected viral cases. They typically prescribed symptomatic relief and requested patients follow-up should they develop worsening or changing symptoms (typically within 5 days). If follow-up was not possible, GPs were more likely to prescribe antibiotics earlier.

“A viral illness will last five days. I prefer to wait, and if there is an increase in fever, a change in the symptoms, worsening cough, greenish phlegm, you’re going to start them on antibiotics at that stage.” (GP-G; female public GP; 19 years’ experience).

GPs acknowledged occasionally prescribing antibiotics without a focus of infection if in doubt or if they suspect the patient may deteriorate, safeguarding the patient and themselves. Some GPs described instances where patients deteriorated, were hospitalised, or died, and they themselves or their colleagues were accused of not prescribing antibiotics immediately. Consequently, fear of missing possible life-threatening illnesses led them to err on the side of caution, even if not always in line with the evidence base.

“I had an adult … I prescribed antibiotics and it turned out to be a virus … I still gave antibiotics … if I missed the boat this person would end up with either a rupture or hearing loss so you can’t afford not to give and then be blamed for not recognizing her condition. It is better to be on the safe side, both for myself and the patient.” (GP-M; male public/private GP; 23 years’ experience).

GPs considered several factors before prescribing antibiotics, including the patient’s smoking status, age, occupation, and co-morbidities. Several believed smokers more often present with bacterial infections and children often acquire viral infections. Elderly patients and patients with multiple co-morbidities, were more likely to require antibiotics early according to GPs, to avoid complications and hospitalisation.

“…often … I end up giving prophylactic antibiotics to 80-year-old patients because if you don’t you end up with a chest infection which is harder to treat. These are people who easily end up hospitalised…” (GP-K; male public/private GP; 19 years’ experience).

GPs often adjusted prescriptions to suit patients’ needs and preferences, to improve compliance. Antibiotic allergies or discomforting side effects (e.g., thrush, nausea/vomiting, diarrhoea) typically led GPs to tailor therapy, changing antibiotic class if necessary. Some GPs also considered flavour (particularly in children), dosage form and regimen, and preferred antibiotics with daily or bidaily regimens.

“Some patients have a real hard time swallowing large tablets and prefer smaller tablets. Compliance is really dependent on these small details.” (GP-F; female private GP; 25 years’ experience).

Category III: GPs’ views on diagnostic testing and its availability in Malta

Few GPs used diagnostic testing (e.g., X-rays, CRP tests, throat swabs, sputum cultures) unless they considered the patient’s condition complicated. Public GPs were more willing to utilise such services due to their availability through the national health service; private GPs often lacked access to diagnostic facilities. Very few GPs were familiar with rapid POCTs. In fact, rapid POCTs for ARTIs were largely unavailable and almost all GPs had never used them. Few private GPs had access to rapid strep tests and only one GP used them regularly. Nevertheless, several GPs expressed positive attitudes towards them and were willing to test them if reliable and time efficient. They believed rapid POCTs could decrease antibiotic overuse and help patients understand their condition and treatment plan. Others insisted they would unlikely rely on rapid POCTs; they would rather rely on their experience and clinical assessment. They perceived rapid POCTs as tools used when unsure of oneself.

“They [rapid tests] would absolutely be very helpful. … You can explain to patients that the results are positive which means you have a bacterial infection… It can be used to persuade the patient rather than basing it just on my clinical impression.” (GP-M; male public/private GP; 23 years’ experience).

Time was considered a barrier to diagnostic testing, including delays caused by referrals and receipt of test results. For rapid POCTs, GPs’ felt they lacked the necessary human resources and infrastructure, which would cause time delays, negatively impacting their practice. Cost was another deterrent among many private GPs. Many believed patients would be unwilling to pay, and that they cannot increase consultation costs as a result. Some believed they may lose clients who will seek care elsewhere instead. This combination of barriers and limited access to testing, often led GPs to prescribe antibiotics empirically, occasionally prescribing a second antibiotic if the first fails to respond, before referring the patient for further investigation.

“We prescribe antibiotics without carrying out bacteriological tests, so we use our clinical judgement to try form an idea of what the underlying bacteriology is and treat it accordingly with the best antibiotic to match the infection.” (GP-J; male private GP; 41 years’ experience).

Category IV: GPs’ views on patient behaviour, knowledge, and awareness

Patient expectations, pressure and demand for antibiotics, non-compliance, and self-medication, were dominant problems reported by GPs. According to GPs, patients seek medical care upon onset of symptoms, even for self-limiting infections, and expect immediate cure.

“…if a patient woke up with a bad sore throat he’ll be seen immediately, and because of this, patients expect an immediate cure. You cannot tell them to come back in three days’ time, they simply wouldn’t grasp that.” (GP-O; male private GP; 26 years’ experience).

Some GPs found demanding patients impossible to persuade and reported that some patients express dissatisfaction when they do not get their way, sometimes threatening to consult another GP. This was viewed as a problem as GPs could lose patients and income as a result. Most GPs, however, felt largely unaffected by this behaviour. Experience was regarded an asset, giving GPs confidence to address such behaviour. Few GPs admitted to buckling under pressure occasionally, even when antibiotics are unnecessary. Some believed this to be harmless; others prescribed short courses, narrow-spectrum antibiotics, or delayed antibiotic prescriptions to reduce harm.

“…when I fail to convince patients, because they literally do not understand, after a lot of thought I figure… one out of ten won’t make … a difference.” (GP-G; female public GP; 19 years’ experience).

Some GPs felt that through increased awareness, antibiotic demand is decreasing, particularly among parents. Nonetheless, several GPs believed patients still harbour misconceptions including that fever requires antibiotics and antibiotics are anti-inflammatory drugs. According to GPs, many do not understand how to use antibiotics appropriately, cannot differentiate between viral and bacterial infections, and believe they cannot recover without antibiotics. Another reported misconception was that the body develops resistance to antibiotics.

Category V: GPs’ experiences with patient education

GPs reported dedicating lots of time towards patient education, viewing it as their responsibility. GPs typically informed patients about their diagnosis, disease progression, and symptom management. GPs also explained the importance of not overusing antibiotics, storing leftovers, self-medicating, or stopping treatment prematurely. Some tried to clarify how resistance develops and its repercussions, but considered it challenging. Although many successfully rationalised with persistent patients why antibiotics are unnecessary, some felt it was pointless when patients insist on getting antibiotics against their advice.

Category VI: Interpersonal dynamics between GPs and other healthcare professionals

GPs mentioned the importance of seeking advice from other physicians (GPs and other specialists) when necessary. Whilst GPs in health centres could rely on colleagues for guidance, some solo private GPs felt isolated. For many solo private GPs who rented clinics within pharmacies, working closely with pharmacists was considered advantageous. They appreciated having access to another healthcare professional to discuss treatment plans and request advice. Conversely, few GPs mentioned that pharmacists sometimes made GPs feel obliged to prescribe medicines.

“Some pharmacists give you horrible looks if the patient doesn’t leave the clinic with a prescription.” (GP-I; male private GP; 39 years’ experience).

Category VII: GPs’ interaction with drug reps

GPs frequently interacted with drug reps but had opposing views towards them and their influence on antibiotic prescription. Drug reps were viewed by many as important contact points, particularly in private practice. To these GPs, the educational and informative aspect of drug-repping was imperative, keeping them abreast with recent medical advancements. They were the GP’s few sources of information on ABR patterns, new drugs, and technologies.

Whilst many GPs appreciated drug reps as credible sources of information, others were sceptical. They believed that information is not always scientifically sound, biased, and sometimes fabricated, since drug reps are under pressure to boost sales. They mentioned that recommendations are based on foreign evidence, and that over the years, drug reps have recommended specific broad-spectrum antibiotics and larger doses as a strategy to prevent ABR. GPs were also wary of certain marketing strategies, e.g., lectures organised and/or sponsored by pharmaceutical companies, incentives, and promoting antibiotics for their anti-inflammatory effect. Several GPs reported pressure from drug reps to prescribe although most insisted it did not influence them.

“I do not think medical reps affect me much. I … take in all the information … but the final decision must be my own…” (GP-F; female private GP; 25 years’ experience).

Category VIII: Primary care organisation

GPs encountered challenges with the healthcare organisation, particularly communication among the primary, secondary, and tertiary sectors. Lack of IT infrastructure resulted in no electronic link with other healthcare providers, often delaying feedback from specialists and hospitals regarding referrals. These delays impacted continuity-of-care and frustrated GPs, deterring them from referring patients. Ensuring continuity-of-care was considered a very important aspect of patient care to many private GPs. Episodic care was believed to lead to a more defensive approach and possibly antibiotic over-prescription.

Category IX: Public policy and guidelines

Few GPs believed that the introduction of professional indemnity insurance in 2014, may have rendered more defensive prescribing practices, i.e., prescribing antibiotics to safeguard oneself from legal implications. Regarding availability of community antibiotic prescribing guidelines and data on local ABR rates, reports were mixed. Whilst public GPs accessed information online, few private GPs seemed aware of this resource; many claimed to have no access to guidelines, despite their availability on the National Antibiotic Committee’s webpage. Several GPs believed in the importance of following guidelines to support diagnosis and treatment, particularly in complicated cases, yet only two GPs actively looked up guidelines; others used them as a last resort. Seldom, GPs felt overburdened and were cynical towards guidelines, placing more value in their experience.

“Often when you reach my age, guidelines just make you laugh. If you want a frank and honest answer, I do not abide by guidelines. Sometimes they are stupid.” (GP-I; male private GP; 39 years’ experience).

GPs noted that ABR data were outdated, and based on inpatient or foreign data, making them less relevant for community practitioners. Several expressed a desire for current, local community data to guide prescribing guidelines and improve GPs’ trust in them. The lack of current ABR data and local guidelines was considered a major pitfall, leading GPs to prescribe more cautiously or aggressively. One GP insisted however, that antibiotics are not abused, rather overprescribed unintentionally; the lack of current local data forces GPs to prescribe antibiotics blindly, without knowing what drug to prescribe or at what dose. Consequently, GPs avoid risks, opting for antibiotics they know are safe and effective.

Patient demand and expectations

GPs experience and are influenced by patient pressure and demand to prescribe antibiotics, which could result in inappropriate antibiotic prescription [46,53–57]. In our recent study, we found that GPs in Malta are more likely to prescribe antibiotics to patients who request them [44], as corroborated by some GPs in this study. GPs believed that patient demand is driven by their expectation for a “quick fix” and belief that antibiotics are the solution, as has been found elsewhere [53]. GPs also believed that some patients lack the necessary knowledge to understand why antibiotics are not always necessary, making them harder to persuade. Indeed, the public’s knowledge and awareness on appropriate antibiotic use remains low in Malta, lower than EU average [23].

Patient expectations and demands are often over-estimated by physicians however, and early expectation-setting is critical to meet patient needs and ensure satisfaction [58]. GPs often mentioned that dissatisfied patients sometimes threaten to consult elsewhere. Since many patients pay out-of-pocket, GPs may feel obliged to prescribe antibiotics to avoid losing clients, avoid reconsultation, and/or ensure patient satisfaction [59]. However, giving patients an antibiotic prescription does not necessarily guarantee satisfaction. Whilst some studies have shown that an antibiotic prescription improves patient satisfaction [54,60], others have indicated that proper examination and information (without antibiotics) leads to higher satisfaction [61–64]. In fact, communication is sometimes valued more by patients than a prescription [65]. Given GPs’ interest in patient education in this setting, introducing educational tools, like images and charts, to support GPs, could be beneficial.

Influence of drug reps

Research shows that drug reps frequently visit GPs, providing one-on-one information during outreach visits [66–68]. Despite most GPs claiming to be unaffected by drug reps, as corroborated by previous studies [69], exposure to information from pharmaceutical companies can negatively impact GPs’ quality of antibiotic prescribing. It could not only augment prescribing but also irrational prescription of the company’s drug [66,68–71]. Such influences can potentially explain the predominance of broad-spectrum antibiotics in Malta in preference to narrower-spectrum alternatives, despite the former not being indicated epidemiologically [72]. It is relevant to highlight, that the proportion of drug reps to doctors in Malta is one of the highest in the EU. It is unlikely that local drug companies were willing to expend so many resources if they did not perceive a satisfactory return on investment. There is no evidence that exposure to promotional activities by pharmaceutical companies improves antibiotic prescribing, therefore continued exposure cannot be recommended [66].

Yet, although some GPs received drug reps with scepticism in our study, GPs often felt that drug reps’ educational and informative role was imperative, similar to other studies [69]. This was particularly prevalent in private solo practices where GPs experienced little interaction with other healthcare professionals. This demonstrates the need for alternate strategies, such as academic detailing, to disseminate scientifically-sound and evidence-informed guidelines. Similar to drug reps’ tactics, in academic detailing, physicians receive individual educational visits by trained healthcare professionals within their own professional setting [73]. It gives GPs the opportunity to reflect on their prescription behaviour and learn about guideline-concordant recommendations for appropriate pharmacotherapy [55]. This can successfully decrease antibiotic prescription rates whilst improving quality and guideline-concordance [74,75]. Since GPs lack time to attend formal lectures, we believe that with enough resources, this strategy can bring correct and timely information to GPs in this type of healthcare setting.

Antibiotic prescribing guidelines

Few GPs believed in the importance of antibiotic prescribing guidelines in this study. Whilst older GPs believed that clinical experience is superior to guidelines, as shown elsewhere [78], GPs were also sceptical about the accuracy of community antibiotic prescribing guidelines which, according to them, were based on foreign guidelines and hospital ABR rates. Lack of trust in guidelines is a major barrier to uptake [78,79]. To build trust, establishment of local community surveillance systems for antibiotic prescribing and ABR, coupled with timely data dissemination to all GPs is critically needed. Surveillance is one of the pillars of ABR containment [1,80,81] and demands urgent attention in this setting. Additionally, guidelines should consider patient needs and preferences, including side effects to specific antibiotics, co-morbidities, and polypharmacy [78,79]. Such factors often affected GPs’ antibiotic prescribing decisions, therefore incorporating patient factors that influence GPs’ likelihood to deviate from recommendations, may further improve adherence.

Rapid POCTs

Rapid POCTs, such as point-of-care C-reactive protein testing, have been shown to reduce antibiotic prescribing rates cost-effectively [82]. When used appropriately, they can guide clinical management and mediate diagnostic certainty by providing GPs a better estimate of illness severity, particularly in settings where access to timely diagnostic services is limited. Rapid POCTs can also provide GPs with negotiating power and an educational opportunity with patients who insist on being prescribed antibiotics [83]. Consequently, GPs may succumb to patient demand less often [84,85], as shown in Spain, where POCTs decreased antibiotic prescription among patients who demanded antibiotics by 18.9% [84]. However, GPs in this study believed that introducing rapid POCTs may be impeded by time constraints, added costs, lack of resources, and patient hesitancy. Despite an overall positive outlook towards rapid POCTs, some GPs would still rather rely on clinical assessment, expecting rapid POCTs to have little impact on their prescribing decisions, as reported elsewhere [83]. Nonetheless, we firmly believe that introducing rapid POCTs in Malta should be considered, although their utility will need to be rigorously assessed to ensure successful scale-up on a national level.

Pharmacists, who already perform rapid POCTs like urinalyses and blood glucose testing in Malta, could possibly collaborate in this strategy. Evidence suggests that involving pharmacists to detect GAS pharyngitis using rapid POCTs and providing Penicillin V treatment when necessary, is more cost-effective than treatment provided by doctors [86]. This approach could alleviate the burden of introducing rapid POCTs into general practices. However, given that several pharmacists run their own private pharmacies in Malta, allowing pharmacists to dispense antibiotics could be impacted by financial gain and should not be overlooked.

Delayed antibiotic prescription

Finally, delayed antibiotic prescribing strategies can also reduce antibiotic use for ARTIs by 45–80%, without significant negative patient repercussions [87–94]. GPs hold varying perceptions about delayed antibiotic prescription however, and there is variation in the way delayed antibiotic prescription strategies are used [95–97]. Whilst this variation cannot be disregarded, appropriate and targeted delayed antibiotic prescription strategies have a role to play in reducing unnecessary antibiotic use, particularly in high uncertainty avoidance cultures, providing reassurance to both the patient and GP [95,98–101]. Incorporating delayed antibiotic prescription into antibiotic prescribing guidelines is also recommended [95].