Antibiotic overuse for acute respiratory tract infections in Sri Lanka: a qualitative study of outpatients and their physicians.


BACKGROUND: Acute respiratory tract infections (ARTIs) are a common reason for antibiotic overuse worldwide. We previously showed that over 80% of outpatients presenting to a tertiary care hospital in Sri Lanka with influenza-like illness received antibiotic prescriptions, although almost half were later confirmed to have influenza. The purpose of this qualitative study was to assess Sri Lankan patients' and physicians' attitudes towards ARTI diagnosis and treatment. METHODS: Semi-structured interviews were conducted with 50 outpatients with ARTIs and five physicians in the Outpatient Department (OPD) at a large, public tertiary care hospital in southern Sri Lanka. Interviews were audio-recorded, transcribed, and analyzed for themes related to ARTI diagnosis and treatment. RESULTS: Patients frequently sought ARTI care in the public sector due to the receipt of free care and the perception that government hospitals carried a sense of responsibility for patients' health. Patients reported multiple medical visits for their illnesses of short duration and many indicated that they were seeking care in the OPD while at the hospital for another reason. While patients generally expected to receive medication prescriptions at their visit, most patients were not specifically seeking an antibiotic prescription. However, more than 70% of patients received antibiotic prescriptions at their OPD visit. Physicians incorrectly perceived that patients desired antibiotics or "capsules," a common formulation of antibiotics dispensed in this outpatient setting, and cited patient demand as an important cause of antibiotic overuse. Physicians also indicated that high patient volume and fear of bacterial superinfection drove antibiotic overuse. CONCLUSIONS: Patients in this study were seeking medication prescriptions for their ARTIs, but physicians incorrectly perceived that antibiotic prescriptions were desired. High patient volume and fear of bacterial superinfection were also important factors in antibiotic overuse. Training of physicians regarding guideline-concordant management and dealing with diagnostic uncertainty, education of patients regarding ARTI etiology and management, and systematic changes in the public outpatient care structure may help decrease unnecessary antibiotic prescriptions for ARTIs in this setting.





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Publication Info

Tillekeratne, L Gayani, Champica K Bodinayake, Thushani Dabrera, Ajith Nagahawatte, Wasantha Kodikara Arachchi, Anoji Sooriyaarachchi, Kearsley Stewart, Melissa Watt, et al. (2018). Antibiotic overuse for acute respiratory tract infections in Sri Lanka: a qualitative study of outpatients and their physicians. BMC Fam Pract, 18(1). p. 37. 10.1186/s12875-017-0619-z Retrieved from

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Gayani Tillekeratne

Associate Professor of Medicine

Global health
Antimicrobial resistance/ stewardship
Acute respiratory tract infections 
Emerging infections/ dengue


Kearsley A Stewart

Professor of the Practice of Global Health

Melissa Watt

Adjunct Associate Professor of Global Health

Dr. Watt's research focuses on understanding and addressing gender-specific health issues in sub-Saharan Africa, with specific attention to HIV, substance use and mental health. In Tanzania, she currently leads an implementation science study aimed at improving access to long-term antiretroviral therapy for pregnant women with HIV. In South Africa, she is collaborating with Dr. Kathleen Sikkema on a study to support HIV care engagement in the context of sexual trauma. In Ghana, she is supporting a team of DGHI graduate students in Global Health to examine the impact of community health workers on the uptake of family planning. Completed research includes the development and evaluation of mental health treatment for women with obstetric fistula in Tanzania, prevention of alcohol-exposed pregnancies in South Africa, and understanding HIV risk behaviors among individuals who use methamphetamine in South Africa.

Dr. Watt directs the Master of Science in Global Health at DGHI and serves as the Associate Director for the Social and Behavioral Sciences Core of the Duke Center for AIDS Research. She has a Ph.D. in Health Behavior from the University of North Carolina, and an M.A. in Gender and Development from the University of Sussex in the U.K.


Christopher Wildrick Woods

Wolfgang Joklik Distinguished Professor of Global Health

1. Emerging Infections
2. Global Health
3. Epidemiology of infectious diseases
4. Clinical microbiology and diagnostics
5. Bioterrorism Preparedness
6. Surveillance for communicable diseases
7. Antimicrobial resistance

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