Table 4 Broad and subthemes derived from the qualitative analyses of changes in the attitudes and behaviour of antibiotic prescribing for URTI during COVID-19

Increase in antibiotic prescribing

More X-rays will pick up more specifics

“When they [the patients] do come in, we are over ordering X-rays, and sometimes the X-ray will describe this equivocal finding, and we will just give antibiotics.” (Institution 2, Medical Officer)

“Maybe twice the number of people [are] getting chest X-rays than they used to, you pick up a lot more of these non-specific findings, when actually they didn’t need the chest X-ray in the first place. And then when people [physicians] see this, half the time, even if you [patient] don’t have a cough or runny nose, some people [physicians] will just give antibiotics and then say, “oh okay, maybe cover for pneumonia” for someone who just came in with giddiness and lethargy, no fever, no cough, no runny nose. Just empirical cover.” (Institution 3, Senior Resident)

Diminished prescribing threshold for prolonged COVID-19 symptoms

“Before COVID[-19], people do not pay much attention about the respiratory tract infection- respiratory symptoms. So, they just stay at home and take some antipyretics and some symptomatic medication by themselves. After COVID[-19], because they are very afraid of getting infected by COVID[-19] and they are aware of all these symptoms, most of the patients come to the ED after [prolonged] condition. I think most of the patients come to the ED need antibiotics because they are very afraid of these symptoms.” (Institution 1, Resident Physician)

“Especially the outpatient setting, when we have COVID[-19] positive patients and patients with a poor premorbid that are immunocompromised. We can imagine that in an outpatient setting, the doctors will be worried about possible bacterial infections manifesting themselves in the first few days of symptoms. Therefore, prescribing antibiotics.” (Institution 1, Medical Officer)

Less time to explain to patients during a busy shift

If we end up X-raying more people and there are more equivocal reports coming out, if the condition arises and if it’s a busy shift, we hardly have any time to make a shared decision making with the patient, then I may just succumb to giving[antibiotics].” (Institution 4, Associate Consultant)

Acceleration of the development of antibiotic resistance

Protocol—To treat COVID-19 pneumonia with antibiotics

“I think unfortunately because any pneumonia from ED is admitted. When they are admitted, we would end up having to treat—or at least our protocol is that we will end up treating for possible underlying bacterial pneumonia rather than a COVID[-19] related pneumonia, so we do start antibiotics. Given how long this pandemic is stretching out, I’m sure eventually some sort of antibiotic resistance will happen.” (Institution 4, Resident)

"Okay maybe COVID[-19] cause more URTI, and people- there is a chance of misusing antibiotics. Maybe higher because the increase in the proportion of URTI patient[s]. So, I think that is probably one of the reason why antibiotic resistance lies from there." (Institution 2, Resident Physician)

Less priority on the development of new antibiotics

“All the pharmaceutical companies are trying to ramp up COVID[-19] production, and COVID[-19] vaccine production […], and the research and development into new antibiotics to tackle the problems of antibiotic resistance maybe pushed further down the line.” (Institution 4, Senior Consultant)

Decrease in antibiotic prescribing

Less consults for non-COVID-19 related URTI complaints

“I would say probably- probably lesser antibiotic prescription now, based on the experience for the last year. Since we are concentrating more on COVID[-19]. I would say like antibiotics are less prescribed for URTI.” (Institution 1, Staff Registrar)

“I think the goal of them coming to ED also have shifted, more on they wanted to get a swab test done. So, they don’t really ask for antibiotics.” (Institution 4, Senior Resident Physician)

An opportunity to educate patients that antibiotics are not necessary for a viral illness

“The truth is during this pandemic, we have even more reason to tell them that antibiotic[s] are unnecessary. If you come pre-pandemic, we are not going to do an X-ray for you. We are not going to do a blood test for you. We are not going to do any kind of swab for you. It’s just based on physical exam, and we send them on their way. So now when you come during the pandemic, we have a much lower threshold for doing X-ray and bloods and of course we have to do the COVID[-19] swab. And so, I find it easier to tell patients “You know what, we have done some test[s]. There is really nothing serious and there is really no need for antibiotics”” (Institution 1, Medical Officer)

I think COVID has taught a lot of people [physicians] that you know it is a viral illness and you don’t go around recommending antibiotics. Starting that piece of knowledge has actually gone out to a lot of common folks, common people in the street. When previously this is a piece of knowledge that they don’t know, [have] never bothered to know.” (Institution 4, Senior Consultant)

No change in antibiotic prescribing

COVID-19 does not change the standard management of URTI

I think in general, there’s no shift in the management for uncomplicated cases. Firstly, even for COVID[-19], there’s no [need] for antibiotics. So, we still give the patient symptomatic medications. (Institution 3, Resident)

Regardless of the COVID[-19] situation, regarding antibiotic practices, I don’t think there’s been much of a change. I think most people still- won’t prescribe antibiotics if they don’t think so.” (Institution 3, Senior Resident)

Baseline antibiotic prescribing was low prior to COVID-19

[In] the ED setting, I don't think it makes much of difference, because COVID[-19] or not COVID[-19], if you should think it's a URTI, you wouldn't be giving antibiotics anyway. (Institution 4, Resident)

I think it (prescribing practices) remains the same. Even more so now because covid is a viral thing right? So, I feel that my colleagues and I feel the same way. A lot of ARI, [are] predominantly viral in nature [and] we really do not have the habit to prescribe antibiotics for such cases. (Institution 3, Senior Consultant)

“I mean COVID[-19] is a viral illness. I don't think antibiotics has anything to, as in I mean antibiotics don't treat COVID[-19]. So, it wouldn't change.” (Institution 2, Resident)