Antibiotic prescribing for respiratory tract infection: exploring drivers of cognitive effort and factors associated with inappropriate prescribing

Nicola McCleary* (Corresponding Author), Jill J Francis, Marion Campbell, Craig Ramsay, Christopher D. Burton

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

2 Citations (Scopus)
4 Downloads (Pure)


Background: Antibiotics are over-prescribed for upper respiratory tract infection (URTI). It is unclear how factors known to influence prescribing decisions operate ‘in the moment’: dual process theories, which propose two systems of thought (‘automatic’ and ‘analytical’),may inform this.
Objective(s): Investigate cognitive processes underlying antibiotic prescribing for URTI and the factors associated with inappropriate prescribing.
Methods: We conducted a mixed methods study. Primary care physicians in Scotland (n=158) made prescribing decisions for patient scenarios describing sore throat or otitis media delivered online. Decision difficulty and decision time were recorded. Decisions were categorised as appropriate or inappropriate based on clinical guidelines. Regression analyses explored relationships between scenario and physician characteristics, and decision difficulty,
time, and appropriateness. A sub-group (n=5) verbalised their thoughts (think-aloud) whilst making decisions for a subset of scenarios. Interviews were analysed inductively.
Results: Illness duration of 4+ days was associated with greater difficulty. Inappropriate prescribing was associated with clinical factors suggesting viral cause, and with patient preference against antibiotics. In interviews, physicians made appropriate decisions quickly for easier cases, with little deliberation, reflecting automatic-type processes. For more difficult cases, physicians deliberated over information in some instances, but not in others, with inappropriate prescribing occurring in both instances. Some interpretations of illness duration and unilateral ear examination findings (for otitis media) were associated with inappropriate prescribing.
Antibiotic prescribing: drivers of cognitive effort and inappropriate prescribing
Conclusion: Both automatic and analytical processes may lead to inappropriate prescribing. Interventions to support appropriate prescribing may benefit from targeting interpretation of illness duration and otitis media ear exam findings; and facilitating appropriate use of both modes of thinking.
Original languageEnglish
Article numbercmab030
Pages (from-to)740–750
Number of pages11
JournalFamily Practice
Issue number6
Early online date11 May 2021
Publication statusPublished - 1 Dec 2021

Bibliographical note

We thank all participants who gave up their valuable time to take part. Thanks also to the Scottish Primary Care Research Network (Amanda Cardy, Jill Sutherland, Marie Pitkethly); Claire Jones (University of Dundee); Ewan Paterson, Graeme MacLennan, Dwayne Boyers, Andy Elder (University of Aberdeen); Eleanor Bull (NHS Grampian); Joanne Preston (NHS Lothian); Ingrid Muller and the LifeGuide team (University of Southampton).

Funding: this work was supported by a Medical Research Council Doctoral Training Grant. The funder had no role in study design, conduct or reporting.

Ethical approval: this study was approved by NHS Grampian National Research Ethics Service (14/NS/0079). Online study completion was taken as implied consent to participate. Interview participants provided informed consent. Data were collected in 2014–15 and stored securely at the University of Aberdeen.

Conflict of interest: the authors declare that they have no competing interests.

Data availability
Data sets are available from the corresponding author on reasonable request


  • Anti-Bacterial Agents
  • Clinical Decision-Making
  • Inappropriate Prescribing
  • Physicians
  • Primary Care
  • Primary Health Care
  • Respiratory Tract Infections


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