# Behavioural Determinants of Appropriate Antibiotic Prescribing for Urinary Tract Infections in Nursing Homes: A Qualitative Study of Stakeholders’ Perspectives

## TL;DR

This study explores why antibiotics for UTIs are often misprescribed in nursing homes by examining the perspectives and behaviors of healthcare professionals and residents.

## Contribution

The study identifies specific behavioral determinants influencing antibiotic prescribing for UTIs in nursing homes using stakeholder perspectives.

## Key findings

- Key determinants include lack of guideline knowledge, fear of missing complications, and social pressure to prescribe.
- Hierarchical relations with physicians and prioritizing resident comfort also influence prescribing behaviors.
- A theory-informed intervention is needed to improve antimicrobial stewardship in nursing homes.

## Abstract

Background/Objectives: Urinary tract infections (UTIs) are the primary indication for antibiotic use in nursing homes (NHs); yet inappropriate prescribing, including incorrect initiation, excessive prophylactic prescribing and prolonged treatment duration, is common. This study aimed to identify key determinants of appropriate antibiotic prescribing for UTIs in NHs by exploring the behaviours and perspectives of relevant stakeholders. Methods: Interviews and focus group sessions with regard to a purposive sample of 4 NHs and healthcare professionals were conducted between June 2023 and April 2024 in Flanders (Belgium). The topic guide was developed based on the Theoretical Domains Framework (TDF). A combination of deductive and inductive coding was used to identify behavioural determinants within each TDF domain. Key behavioural determinants were identified based on their importance, relevance, and feasibility. Results: We conducted 31 semi-structured interviews with residents/relatives (n = 13), physicians (n = 9), pharmacists (n = 10), and NH management (n = 5) and held 4 focus group sessions with nurses (n = 16) and nurse aides (n = 10). Appropriate antibiotic prescribing for UTIs in NHs was influenced by a complex interplay of behavioural determinants. Key behavioural determinants included lack of knowledge of guidelines, lack of self-reflection and monitoring, fear of missing complications, feelings of powerlessness, prioritising residents’ comfort, hierarchical relations with treating physicians being dominant, social pressure to prescribe, and the NH as a challenging context. Conclusions: This study identified key behavioural determinants that should be targeted to optimise antibiotic prescribing for UTIs in NHs. These findings underscore the need to conduct a theory-informed, multifaceted intervention to support behaviour change across professional roles and improve antimicrobial stewardship in this setting.