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Table 2 Domains, themes, and representative quotes regarding acute respiratory tract infection (ARTI) diagnosis and treatment for OPD physicians at a tertiary care hospital in southern Sri Lanka

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

Domains Themes Representative quotes
Diagnosis and management of ARTIs Clinical symptoms can help differentiate viral and bacterial ARTIs “At the beginning, same symptoms. After 2–3 days we can differentiate… If continuous fever, and if patients complain more and more, develop more severe illness, are more dyspneic, have more fever, and are more acutely ill [then it is bacterial]”- OPD003
“Viral of course, it is mild fever, sometimes body aches, headache, loss of appetite, so on. Based on our own experience, we know…. Viral of course nothing but symptomatic and supportive treatment…. We give paracetamol, piriton [antihistamine], and so on.”- OPD004
Laboratory testing in the OPD is minimal “It’s a problem because we can’t do cultures here. Blindly we treat with antibiotics usually.”- OPD002
“So we do the basic investigations and see for the response and after that we treat…. Yes, if we can get that rapid testing then the treatment will be very vigilant. And we can expedite.”- OPD004
Antibiotic over-prescription Patients demand antibiotics “That’s tricky because patients here, in Sri Lanka I don’t know, they sometimes ask for antibiotics because they are used to getting them…. They take very low doses of antibiotics. And they come and say this is what I’m taking. So sometimes we have to continue the antibiotics with the normal dose. Like the adult dose…. They say, ‘With antibiotics only, I get relief.’ So it’s a nuisance to us.” – OPD001
“Medically not indicated, but we have to weigh the conditions and the patient. Some patients, they are coming while they are going to work…. They are finding day-to-day income. The family gets disturbed due to the lack of income. Most of the time, they are asking for a one-shot treatment…. They say ‘Sir, there is no capsule given here’- that is what. They are experienced, they need some form of capsules.”- OPD004
Diagnostic uncertainty and bacterial superinfection “Viral ones we sometimes treat with some antibacterial cover-up, otherwise they will develop secondary bacterial infections. Usually we do so.”- OPD003
“For viral-- joint pain, back ache, loss of appetite [are common]…. If I’m sure, then I don’t give an antibiotic. If I’m not sure, I often use an antibiotic.”- OPD005
Children are more vulnerable than adults “Children of course, I start antibiotics a little bit earlier than with adults. Because with my experience, I think that even at home I give them antibiotics a little bit earlier. If my child is ill for 3–4 days, I start antibiotics. Sometimes I practice that in the OPD as well. In my experience, I think that they get better. I don’t know if it’s the wrong thing.”- OPD001
“A child needs special attention…. Sometimes on the first or second day we try anti-inflammatories and antibiotics.”- OPD003
Competition with private sector/other doctors “Competition is if I am not prescribing an antibiotic from the first day, sometimes it can be a bacterial one [infection], and on the second, third day the patient will get more severe symptoms and go to another practitioner. Then [the practitioner will say] ‘this is pneumonia’ and they will start [antibiotics]. Then the first person will get less marks…. Mother or some relative will say that this is the best physician…. His treatment is much better than the other one, then the first person will get less respect. Because of competition, most of the time in the private sector, they use antibiotics.”- OPD003
Antimicrobial resistance Lack of awareness of antimicrobial resistance “But actually, about antibiotic resistance, so far I have no experience. Just by treating patients very often, we give treatment for three or four days. After that sometimes they won’t come to us. But bit difficult to assess whether they have developed antibiotic resistance or not.”- OOP004
Opportunities for improving ARTI care Continued physician trainings “What I think is that if you can educate our doctors from time to time, with these epidemics, their nature, and how to treat them, then of course it is really beneficial. I’ll tell you that most of the doctors do not read about these conditions. They won’t go through these leaflets or those results papers.”- OPD004
Need for systematic changes “If there were a longer time duration in the OPD for the patients. If we can allocate 5 min or so per patient, then we can improve things…. If something is given free of charge, they will take anything. While just waiting, they come and get medications…. The patient who comes to go to the bank gets a ticket from the OPD [number to wait in line], goes to the bank to get their work done, then comes again to get medication. Actually, it’s not for a real need that they take medications…. Not a large amount, but [by charging] a small amount like 50 Rupees, it’s possible to reduce it. If five people come, all five will get a ticket. If you charge 50 Rupees, then only the person in need will take the medication.”- OPD005