Table 5 Meta-inferences on the changes in Emergency Department Physicians’ attitudes and behaviour on antibiotic prescribing after data integration

1

There is less pressure to prescribe antibiotics due to diminished patient demand for antibiotics and having more opportunities to educate patients on viral illnesses

High prescribers were more likely to succumb to pressure to prescribe antibiotics pre COVID-19 [OR: 1.74, 95% CI (1.12, 2.71)]. The pressure faced by high prescribers diminished during the COVID-19 pandemic [OR: 0.99, 95% CI (0.70, 1.41)]

Regardless of COVID-19, high prescribers were more likely to think that patients who attend the ED are demanding [OR: 1.44, 95% CI (1.09, 1.89)] and that educating patients about antibiotic use will reduce their work pressure in handling patients with URTI [OR: 1.46, 95% CI (1.05, 2.02)]

Some ED physicians felt that the focus of URTI-related ED visits has shifted to getting a COVID-19 test rather than asking for antibiotics during the pandemic. The pandemic had also provided them with the opportunity to introduce the concept of viral illnesses to their patients

2

A higher proportion of ED physicians self-reported lower antibiotic prescribing rates during the COVID-19 pandemic but their perception of the overall outlook on antibiotic prescribing rates varied

ED physicians were twice as likely to self-report that they prescribed antibiotics for > 10% of URTI patients pre COVID-19 [OR: 2.12, 95% CI (1.32, 3.41)]. There was no difference in the perception of antibiotic over-prescribing between high and moderate prescribers regardless of COVID-19 [OR: 1.19, 95% CI (0.92, 1.54)] (the interaction term for this factor was dropped from the model)

Some physicians had the perception that more antibiotics were prescribed due to more diagnostic tests (X-rays) leading to over-diagnosis; some felt that there was no change in prescribing patterns due to COVID-19 due to its viral nature; some felt that the pandemic had given them the opportunity to reduce unnecessary antibiotic use

3

Physicians who were high antibiotic prescribers during the COVID-19 pandemic made less effort for prudent antibiotic prescribing as they were less concerned about antimicrobial resistance

There was no difference between high and moderate antibiotic prescribers pre COVID-19 in the effort to prescribe antibiotics prudently [OR: 1.10, 95% CI (0.73, 1.66)]. However, high prescribers were less likely to make an effort to prescribe antibiotics prudently during the COVID-19 pandemic [OR: 1.54, 95% CI (1.09, 2.18)]. Physicians concerned about antibiotic resistance would tend to make an effort to prescribe antibiotics prudently (the Likert item “I avoid prescribing antibiotics for patients with URTI because I am concerned about antibiotic resistance” was part of the behaviour-related factor "effort to prescribe antibiotics prudently")

There was no significant difference in the distribution of this Likert item between high and moderate prescribers pre-COVID-19 (pre-COVID-19 mean (SD): 4.01 (0.78); during COVID-19 mean (SD): 4.22(0.65); P = 0.058), but high prescribers were significantly agreeing less to this statement during COVID-19 (pre-COVID-19 mean (SD): 3.68 (0.78); during COVID-19 mean (SD): 4.18 (0.68); P < 0.001).)

Many physicians expressed concern about (1) the acceleration of antibiotic resistance due to less priority on the development of new antibiotics and (2) the possible less prudent use of antibiotics due to COVID-19. Some of them mentioned that their concern about antimicrobial resistance had led them to prescribe antibiotics more prudently

4

COVID-19 did not change the factors that lowered the threshold for antibiotic prescribing

High prescribers were more likely to lower their threshold for antibiotic prescribing for patients who are immunocompromised, elderly, suspected of borderline bacterial infection, and have reattended the ED regardless of COVID-19 [OR: 1.83, 95% CI (1.37, 2.42)]. The COVID-19 interaction term was dropped as there were no significant differences in lowering the threshold for antibiotic prescribing pre- and post-COVID-19

Physicians would lower their antibiotic prescribing threshold for COVID-19 patients with poor premorbid or are immunocompromised

5

COVID-19 did not change the perception that the public's knowledge of antibiotics is poor

The factor "Insufficient patient education" was dropped from the logistic regression model as the variable did not contribute significantly to the model. There were no significant differences in perceptions among high/moderate prescribers and pre-or post-COVID-19

Physicians mentioned that despite improvement in the publics' awareness of antibiotic use in recent years, the public still lacked appropriate knowledge on antibiotic use. Therefore, the COVID-19 pandemic provided them with the opportunity to educate patients on appropriate antibiotic use if patients requested for antibiotics during the pandemic