Diagnostic uncertainties as driver of antibiotic prescription in low-resource settings: secondary qualitative analysis of junior physicians’ perspectives

Antimicrobial resistance (AMR) is a growing global health threat driven in part by suboptimal antibiotic use. Diagnostic uncertainty in clinical practice can contribute to unnecessary or precautionary antibiotic prescribing, particularly in resource-limited settings. This study aimed to explore how physicians in secondary-level hospitals manage diagnostic uncertainties during antibiotic prescribing. This study involved a secondary analysis of qualitative data collected from two secondary-level hospitals in Rwanda: Nyamata Level Two Teaching Hospital and Nyarugenge District Hospital. Physicians involved in antibiotic prescribing were recruited through convenience sampling until data saturation was achieved. Data were collected using semi-structured interviews. An inductive thematic analysis was conducted, whereby codes were identified as units of meaning and subsequently grouped into related subthemes and overarching themes. A total of 24 physicians participated, all of whom were general practitioners aged below 35 years. Three major themes emerged. The first theme (Physician’s uncertainties tolerance) included concerns about disease progression and the risks of avoiding antibiotic prescription. The second theme (Avoiding unjustified prescription) encompassed strategies such as watchful waiting, requesting additional laboratory investigations, and consulting senior colleagues. The third theme (Feeling safer to treat with antibiotics) reflected approaches including “treat first, adjust later” and initiating definitive antibiotic treatment despite diagnostic uncertainty. These themes reflect systematic pressure physicians face during antibiotic prescription, with urgency to decide when evidence is not definitive. The findings demonstrate variability in how physicians manage diagnostic uncertainty during antibiotic prescription, with the systematic pressure to decide. While some prioritize minimizing unnecessary antibiotic exposure, others focus on preventing potential clinical deterioration. Incorporating clearer guidance on managing diagnostic uncertainty into treatment guidelines may help standardize prescribing practices and strengthen antimicrobial stewardship efforts.