Table 2 Main findings of the included studies

Palin, et al. [25]

Significant variability in antibiotic prescribing between practice and within practices was observed. This variability is influenced by patient characteristics which play a role in shaping antibiotic decisions

Prescribing guidelines, and more targeted interventions are needed

Lum, et al. [6]

The main challenges to prudent antibiotic prescribing are patient expectations, colleagues' prescribing habits, cultural norms, and professional routines; and uncertainty of diagnosis coupled with prescribing pressure of patients

Upskilling physicians to manage patient’s expectations efficaciously

van der Velden, et al. [20]

Point-of-care testing can confidently overturn judgements made to prescribe antibiotics solely based on clinical criteria, it could improve the quality of antibiotic prescribing decisions

The Point Prevalence Audit Survey is regarded as an important research tool, and the country-specific data it contains can help in developing and putting into practice antibiotic management initiatives

Theodorou, et al. [26]

Source of information, cost of drugs, clinical effectiveness, attitudes of physicians towards generic prescribing and innovation, and patient preference are important factors for Prescribing behaviour of physicians

When formulating policies to help physicians make better decisions and, as a result, improve clinical and financial effectiveness and efficiency, the health care system should place particular emphasis on the attitudes and factors

Queder, et al. [18]

The context of physicians' practices, the length of their work experience, and system-level influences have been identified as significant influences on their perceptions of antibiotic prescribing

Intervention studies must be conducted at a large scale to adequately investigate the diverse environment around physicians' practices

Chan, et al. [27]

Time pressures and patient demands can influence physicians' antibiotic prescribing decisions based on organizational practice norms

Patient education targeting at individual, interpersonal and community levels, could reduce unnecessary antibiotic use

Ahmadi and Zarei [28])

Perception and knowledge of physicians, the socioeconomic characteristics of patients, and the pattern of the disease can lead to irrational drug prescribing among family physicians

Training on rational use of antibiotics, and continuing education for physicians

Kotwani, et al. [29]

Important factors identified for antibiotic prescription by physicians were perceived demand and expectation from the patient, diagnostic uncertainty, practice sustainability, financial consideration, influence from medical representatives and inadequate knowledge

To encourage sensible use of antibiotics in the community, interventions such as continuing medical education for doctors, patient education, shared decision-making, and stronger laws and regulations were proposed

Fletcher-Lartey, et al. [30]-

Many doctors did not believe that the use of antibiotics in primary care was the cause of the rise in antibiotic resistance, nor did they believe that their own prescribing would have much impact given other, more important problems, such as hospital prescribing

There is a need to increase awareness of the scope and magnitude of the role primary care prescribing plays, antibiotics resistance and the contribution of individual prescribing decisions to the problems of antibiotics

Laka, et al. [31]

The use of guidelines, years of experience, and type of setting were factors of antibiotic prescribing

Designing targeted and tailored interventions for appropriate antibiotic prescribing and promote rational antibiotic prescribing practices in primary care practice and hospital settings

Swe, et al. [32]

The inter-prescriber heterogeneity in antibiotic prescribing decisions was found to be significantly influenced by several patient variables, including past antibiotic use, patient age, clinical context, and management

When developing trials and stewardship programs intended to lessen unnecessary antibiotic prescriptions, intra-prescriber variance should be considered

Mousquès, et al. [33]

Only 6% of the overall variation was related to inter-physician variability, with intra-physician variability accounting for a considerable portion (70%). Differences in early medical education, continuing medical education and more broadly the sort of medical information transmission may have an impact

Policymakers should consider the variability of antibiotic prescription among physicians in primary health care settings to develop facilitators for promoting better use of antibiotics when it is interested

Björnsdóttir, et al. [34]

The diagnostic techniques used by the doctors were very variable and individual, in contrast to being consistent throughout time. Physicians' professional experience, clinical guidelines, continuing education, and patient presentation are some of the causes for the contrast between individual variability and consistency over time in diagnostic procedures. This difference has an ongoing impact on doctor practises' decisions to prescribe antibiotics

General practitioners may need to modify their diagnostic strategies in light of new knowledge and technologies because the medical sector is continually changing

Bharathiraja, et al. [35]

Factors like experience of physician, postgraduate qualification, source and method of updating knowledge, inpatient practice setting and clinical symptoms influenced the antibiotic prescription

The task of raising doctors' understanding of the usage of antibiotics should be taken on by professional organizations

Cadieux, et al. [36]

Doctors with busy practises, and practitioners with less experience were more likely to give antibiotic prescriptions that were not necessary

More understanding of the mechanisms behind these factors of incorrect antibiotic prescribing will be necessary to create effective therapies

Skodvin, et al. [37]

Key factors influencing antimicrobial prescribing practises were identified as patient assessment, informal training by experienced colleagues, and infectious diseases specialities replacing managers in promoting prudent prescribing policies

Before developing sustainable and tailored antimicrobial stewardship programs interventions may first identify important stakeholders and organizational obstacles

Guo, et al. [38]

Financial factors, drug formulary management, patient load, and a strong patient‒physician relationship were shown to be crucial for effective antibiotic prescribing. multiple factors influencing antibiotic prescribing in primary care

Reduced inappropriate prescribing practices can be achieved in part by implementing shared decision-making in primary healthcare settings

Borek, et al. [39]

Antibiotic prescribing and engagement with AMS in primary healthcare settings in England are influenced by social and contextual factors on multiple levels (individual, local, practice, and national

It is critical to shift the emphasis towards giving prescribers, practises, and commissioners more assistance in their initiatives to enhance antibiotic prescribing practices

Béjean, et al. [40]

The scope and degree of medical intervention are influenced by patient features, individual circumstances, and the socioeconomic environment. The type of compensation, competitive environments, and financial incentives, on the other hand, have a higher impact on physician activity

To understand physicians’ behaviour and response to policy incentives, policymakers should consider the variety in physicians' practice patterns

Sydenham, et al. [41]

Creative protein level, general condition-guided, generalists, stethoscope-guided, reluctant prescribers, and are influenced factors to prescribe antibiotics for acute respiratory tract infection

In the fight against antibiotic resistance, the use of CRP testing is crucial to promote reasonable antibiotic use

Schwartz, et al. [12]

Significant inter-physician variation exists in the prescription of antibiotics in primary health care settings. Patient features could not account for this variation

The inter-physician diversity of family physicians should be considered in innervations

Aabenhus, et al. [8]

Higher prescribers of antibiotics in Danish general practice can be identified by organisational and diagnostic variables. These variables could be the size of the practice, the accessibility of prescription guidelines or protocols for antibiotics, the existence of quality improvement projects, and the degree of cooperation amongst healthcare professionals working for the same company

There is a constant demand for the general practice sector to seek to decrease the overuse of antibiotics

Pouwels, et al. [42]

Variations in comorbidity prevalence cannot account for the majority of practice-level variation in antimicrobial prescribing. The possibility for a practice to minimise prescribing may be determined by considering factors like high consultation rate for acute respiratory tract infection and higher prescription rate for corticosteroids, which may explain a large portion of the difference

Provide targeted education and training programs for healthcare providers on evidence-based guidelines for appropriate antibiotic prescribing

Paluck, et al. [43]

Perceived pressure from parents was identified by physicians as a major factor in antibiotic prescribing in this survey

A comprehensive strategy and demand that the general public be educated on current upper respiratory tract infection treatment concepts and antimicrobial medication resistance

Kumar, et al. [44]

The doctor-patient relationship, biomedical evidence, policy statements, clinical experience, social context, service provision and individual knowledge of patients were a given factor that led to prescribe antibiotics

Implement electronic clinical decision support systems within electronic health records

Simpson, et al. [45]

Updating guidelines on antibiotic prescribing for physicians is crucial to emphasize the significance of appropriate antibiotic use in containing the problem of antimicrobial resistance

Develop multifaceted therapies that target both diagnostic and operational issues by integrating educational programmes, clinical decision assistance, and system-level adjustments

Wood, et al. [46]

The primary factors for prescribing antibiotics were clinical considerations such as the presenting conditions, patient circumstance, the perceived need to treat the infection immediately and effectively, the likely infecting organisms, perceptions of resistance and treatment failure, a duty to provide patients with the opportunity to benefit and likelihood of re-presentation

The strategies to change broad-spectrum antibiotic prescribing will need to consider clinicians’ perceptions of social responsibility

Reynolds and McKee [47]

The existence of financial incentives and the limited availability of information on appropriate prescribing, Perceptions of antibiotic resistance, knowledge gap, and inadequate guidance are the main factors for inappropriate of antibiotics

A multifaceted approach that includes increased surveillance, harmful incentives being replaced with ones that encourage best practise, and education based on an understanding of existing attitudes

Bjorkman, et al. [48]

The prudent antibiotic prescription was hindered by the patient's caretaking priority, a lack of attention on restricted antibiotic use, a lack of knowledge about how to treat infectious infections, or pressure from the healthcare organization

Collaboration across disciplines; for effective antibiotic resistance prevention, cooperation amongst healthcare experts is necessary

Björkman, et al. [49]

Restrictive antibiotic prescribing was considered crucial to combat antibiotic resistance, although the actual prescribing was greatly influenced by the interaction between patients and physicians

Training in communication skills is essential for physicians and other healthcare workers

Vazquez-Lago, et al. [50]

Complacency, fear, patient’s insufficient knowledge and external responsibility of the pharmaceutical and over-the-counter antibiotics were the factors that influenced the prescription of antibiotics by general practitioners

No

Akkerman, et al. [51]

In daily practice, it has been noted that physicians can overestimate the severity of symptoms and might think that patients have higher expectations when considering whether to prescribe antibiotics for respiratory tract infections. This propensity may lead to the misuse of antibiotics in cases where they may not be required or effective

Using patient-centred counselling techniques to justify the prescription of antibiotics

Wester, et al. [52]

The improvement of antibiotics prescribing and infection control practises may be restricted by disparities in physician knowledge, beliefs, and attitudes. Encouraging the use of alternative therapies, putting guidelines into place, and making sure doctors provide patients with the right advice, it is critical to overcoming disparities

The treatments that provide knowledge without influencing clinicians' actions were the most appreciated. These interventions included giving out up-to-date antibiograms, administering antibiotics in accordance with institution-specific prescription guidelines, and holding grand rounds on antibiotic prescribing and antibiotic resistance

van der Zande, et al. [53]

Experience and confidence in clinical decision-making are crucial factors in addition to acknowledging patient concerns and reaching shared decisions during consultation. However, time pressure, especially time availability for consultation can have an impact on increased antibiotic prescribing in primary healthcare. During the decision-making process, effective communication between doctors and patients, as well as addressing patients' expectations, significantly influences antibiotic prescribing

Population-level initiatives and clinician-led programs have demonstrated the efficacy of communication-based interventions directed at the general public in lowering antibiotic prescribing

Chem, et al. [54]

The socioeconomic status of patients in public health facilities, the drug availability in healthcare facilities, and the in-service training of prescriptions in private healthcare facilities were all recognised as factors that affect antibiotic prescription

Performance Based Financing scheme should apply in primary health care settings and prescribing should only be done by physicians as they have adequate training

Beilfuss, et al. [55]

Understanding physician prescribing behaviour for antibiotics requires consideration of aspects such as physician affiliations, characteristics, quantity of treatment, and patient characteristics

Additionally, the use of antibiotics by doctors has been measurably affected by physician-based policy

Promote effective medical service delivery and high-quality care through better physician coordination and accountability

Zetts, et al. [56]

Patient demand, physician perceptions of broader quality measurement systems, financial incentives, patients' past experience of receiving antibiotics from another clinician, physicians’ belief that antibiotic knowledge deficits were key drivers of overprescribing

The intervention for Antibiotic Stewardship Program should consider physician attitudes and beliefs about antibiotic stewardship

Rodrigues, et al. [57]

The difference in opinion between physicians working in hospitals and primary care can have impact on the quality of antimicrobial prescribing. These disparities arise due to patient volume, specialist expertise, treatment guidelines and practice and resource availability

The intervention to improve antibiotic prescription quality should be costumed for each setting, especially considering the more evident difference between primary care and hospital attitudes

Alradini, et al. [58]

Professional status, Workplace, and duration of clinical practice were factors prescription of antibiotics by primary health care physicians. The senior and more clinical experienced physicians with higher professional degrees had higher control towards antibiotic prescription

Regular conferences, workshops, and continuing medical education are used to train physicians to expand their knowledge

Tang, et al. [59]

Public reporting can positively influence antimicrobial prescribing patterns of doctors particularly for acute respiratory tract infections in primary health care settings, with reduction in the prescription rate of antibiotics and use of antibiotics

Public reporting intervention with special concentration on the physician prescription patterns

Rodrigues, et al. [60]

Working in the emergency department, workload, and physicians’ attitudes were identified as critical factors affecting antibiotics prescriptions

Junior doctors' knowledge and clinical behaviour should be improved, and decision-makers should be made aware of the connection between higher workload and subpar performance when prescribing antibiotics

Al-Homaidan and Barrimah [61]

Physicians have some shortage of knowledge and attitude about antibiotics regarding beneficial effects of antibiotics, the efficacy of alternatives to antibiotics, antibiotic resistance, harmful effects of antibiotics, practice guidelines, and the advice that should be given to patients who are prescribed antibiotics

The adoption of practice guidelines, bettering patient awareness and education, and rules for prescription and dispensing antibiotics are some of the more targeted treatments that primary healthcare providers need

Frost, et al. [62]

Knowledge deficits regarding current guidelines, specialities and peer prescribing habits, experience, confidence level treating patient and parent factors were main barriers for antibiotic prescription. Additionally, diagnostic uncertainty is a leading driver of antibiotic prescribing

To focus Antibiotic Stewardship Program efforts; research on the knowledge, attitudes, and beliefs influencing prescribing practices can be useful

Karimi, et al. [63]

Study of experience, cultural and societal characteristics, and belief in the significant impact of antibiotic prescription. Self-medication, as well as the people's habits and cultural elements as a whole, encourage them to recommend doctors who frequently prescribe antibiotics

There is a need to increase family doctors' knowledge and proficiency in prescription antibiotics in the primary healthcare setting

Huang, et al. [64]

Diagnostic uncertainty and knowledge gaps, Organizational-related factors (organization norms and culture) were determinants of antibiotics prescribing practices

Antibiotic prescribing can be made more effective by modelling institutional best practice standards and clinical decision support systems based on local epidemiology

Sharaf, et al. [65]

Practitioners mainly physicians, patients and the organizations themselves played a role in shaping antibiotic uses and prescribing practice in primary healthcare centres. Patient’s behaviour, patient pressure, workload and restricted time of consultation and management response to patient complaints were strong factors of antibiotic prescribing practices

Effective behavioural change initiatives should consider a variety of elements, including individual and organizational aspects

Poss-Doering, et al. [66]

Continuity of care, patient expectations, uncertainty regarding diagnosis, prognosis, and when not knowing the patient are main factors in physicians' developed habits in decision-making on antibiotics prescribing

No

Liu, et al. [67]

Antimicrobial prescribing practices are complex processes and associated with external factors; financial incentives, patient pressure and time pressure) and intrinsic regarding prescriber (knowledge and attitude)

It is crucial to implement policy initiatives that focus on external issues connected to the prescription of antibiotics

Cordoba, et al. [68]

The variability of antibiotic prescription is explained by diagnostic uncertainty and contextual characteristics beyond clinical practice

Providing physicians with evidence-based guidelines and tools to apply them