The study, led by Jerome Ndayisenga of the National Reference Laboratory at Biomedical Centre in Kigali, took the form of a secondary qualitative analysis drawing on semi-structured interviews conducted at two secondary-level hospitals: Nyamata Level Two Teaching Hospital and Nyarugenge District Hospital. The researchers recruited physicians involved in antibiotic prescribing through convenience sampling, continuing until data saturation was achieved. In the end, 24 physicians participated, all of them general practitioners under the age of 35. That demographic detail matters: these are the front-line clinicians who handle the bulk of patient encounters in district and teaching hospitals across Rwanda and much of sub-Saharan Africa, often with limited access to laboratory confirmation and without the safety net of specialist backup.

Using an inductive thematic analysis, the team treated individual codes as units of meaning and grouped them into subthemes and overarching themes. Three major themes emerged from the data, and together they sketch a portrait of clinicians caught between competing risks. The first theme, which the authors labeled physician uncertainty tolerance, captured the participants’ concerns about disease progression and the dangers of withholding antibiotics when a bacterial infection could not be ruled out. For a junior physician watching a febrile patient whose condition might deteriorate overnight, the fear of doing nothing can outweigh the abstract, population-level harm of an unnecessary prescription.

The second theme, avoiding unjustified prescription, revealed the defensive strategies some physicians deploy to resist that pressure. Participants described practicing watchful waiting, ordering additional laboratory investigations such as full blood counts and C-reactive protein tests, and consulting senior colleagues before committing to antimicrobial therapy. These behaviors represent deliberate attempts to buy time and gather evidence, converting an intolerable moment of uncertainty into a manageable, staged decision. Yet the study makes clear that such strategies are unevenly applied, depending on the individual clinician’s risk tolerance, the patient’s presentation, and the practical constraints of the hospital in question.

The third theme proved to be the most consequential for antimicrobial stewardship. Participants described feeling safer to treat with antibiotics, adopting an approach the authors characterized as treat first, adjust later. In this mode, physicians initiate definitive antibiotic treatment despite diagnostic uncertainty, planning to revisit the decision once laboratory results arrive or the clinical picture clarifies. The logic is clinically defensible on an individual basis, sepsis and other bacterial infections can kill within hours, but multiplied across thousands of encounters, it becomes a systematic engine of unnecessary antibiotic exposure.

What unites the three themes, the authors argue, is a form of systematic pressure: the urgency to decide when the evidence is not definitive. In secondary-level hospitals, where microbiology capacity is often limited and antimicrobial susceptibility tests may be unavailable or slow, the clinician’s uncertainty cannot simply be resolved by better data. Laboratory investigations such as full blood counts and C-reactive protein measurements provide probabilistic signals rather than definitive answers, and turnaround times may stretch beyond the window in which a treatment decision must be made. The result is a clinical environment in which prescribing becomes the default escape route from ambiguity.

The study’s grounding in Rwanda gives it particular weight in the global conversation about antimicrobial resistance. Low- and middle-income countries bear a disproportionate share of the AMR burden, driven by a combination of high infectious disease prevalence, constrained diagnostic infrastructure, and, in some settings, over-the-counter antibiotic availability. Secondary-level hospitals occupy a critical position in this landscape: they are the first point of formal medical contact for many patients, staffed largely by junior general practitioners, and equipped with laboratories that fall short of the reference facilities found in national hospitals. Understanding how prescribing decisions are made at this level is therefore essential to any realistic stewardship strategy.

The variability the researchers documented is itself a finding. While some physicians prioritized minimizing unnecessary antibiotic exposure, employing watchful waiting and repeated consultation to hold the line, others focused on preventing potential clinical deterioration, treating early and adjusting later. This heterogeneity means that two patients with similar presentations at the same hospital may receive markedly different antibiotic decisions depending on which clinician sees them. From a stewardship perspective, such inconsistency is a problem in its own right, because it undermines guideline adherence and makes prescribing patterns difficult to predict, monitor, or correct.

The authors’ central recommendation follows directly from their data: treatment guidelines should incorporate clearer, more explicit guidance on managing diagnostic uncertainty. Current guidelines tend to assume a level of diagnostic clarity that often does not exist at the point of care, leaving junior physicians to improvise their own risk calculations. Embedding structured decision pathways, for instance, specifying when watchful waiting is safe, which investigations should precede treatment, and how to sequence empirical therapy with planned review, could standardize prescribing practices and reduce the discretionary variability that the study observed. Such guidance would function as a cognitive aid, redistributing some of the decision-making burden from the individual clinician to the institutional protocol.

Beyond the Rwandan context, the study speaks to a growing recognition within antimicrobial stewardship research that prescribing behavior cannot be changed by guidelines and audit alone. Diagnostic uncertainty is a psychological and structural phenomenon, and it demands interventions that operate at both levels: rapid diagnostics that shrink the uncertainty itself, and training and protocols that help clinicians tolerate the residual uncertainty without defaulting to antibiotics. For the junior physicians at the center of this study, every ambiguous fever is a small ethical dilemma between the patient in front of them and the future patients who will inherit the consequences of resistance. The research suggests that the most effective stewardship programs will be those that acknowledge that dilemma, rather than pretending it can be resolved by willpower alone.

Subject of Research: Diagnostic uncertainty and antibiotic prescribing practices among junior physicians in low-resource settings

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

Article References: Ndayisenga, J., Mugabo, E., Ntiyamira, S., Bugingo, J. P., Musabeyesu, G., Sibomana, O., Umuhoza, A., Bimenyimana, P. C., Igizeneza, A., Gahamanyi, N., Gashegu, M., Mukagatare, I., Ngabonziza, J. C. S., & Fitch, M. I. (2026). Diagnostic uncertainties as driver of antibiotic prescription in low-resource settings: secondary qualitative analysis of junior physicians’ perspectives. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15709-2

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15709-2

Keywords: antimicrobial resistance, diagnostic uncertainty, antibiotic prescribing, Rwanda, qualitative research, antimicrobial stewardship, junior physicians, secondary-level hospitals, low-resource settings, clinical decision-making, Diagnostic, uncertainties

The scale of the problem is striking. Globally, studies consistently estimate that 30 to 40 percent of pediatric antibiotic use is unnecessary, much of it driven by the treatment of viral upper respiratory tract infections that derive no benefit from antibacterial drugs. In Oman, a national multicenter audit found that 37 percent of pediatric antimicrobial prescriptions were inappropriate, with a disproportionate reliance on broad-spectrum agents such as third-generation cephalosporins. These agents, which include combinations like amoxicillin–clavulanate and later-generation cephalosporins, act against a wide range of bacteria, and their overuse accelerates the selection of resistant organisms while exposing children to avoidable adverse effects and higher costs.

Why do frontline settings struggle so much with appropriate prescribing? The review points to a convergence of pressures that clinicians in emergency and primary care know intimately. Diagnostic uncertainty is particularly acute in infants and young children, who often present with non-specific symptoms that make it difficult to distinguish a self-limiting viral illness from a bacterial infection requiring treatment. Limited access to point-of-care diagnostics compounds the problem, pushing clinicians toward empirical prescribing as a safety measure. Parental expectations add another layer: parents who believe antibiotics will speed their child’s recovery frequently request them, and time-pressed clinicians may comply. In Oman specifically, the authors note additional structural challenges, including variable prescribing autonomy across facilities, limited local antibiogram data in community settings, and inconsistent training in stewardship principles.

The stakes of getting this right extend far beyond individual prescriptions. Primary care clinics and emergency departments together account for approximately two-thirds of all antibiotic prescriptions for children worldwide, making them the central arena in which resistant pathogens are either contained or allowed to circulate. Without consistent stewardship across both community and emergency sectors, the review warns, resistant bacteria move freely between hospitals and outpatient environments, undermining public health gains achieved in any single setting. This interconnectedness means that a stewardship program confined to a tertiary hospital, however successful, cannot protect a population if prescribing practices in the clinics and emergency rooms that feed into it remain unchecked.

International guidance offers a clear framework. The American Academy of Pediatrics and the World Health Organization emphasize prescribing antibiotics only when bacterial infection is strongly suspected, favoring narrow-spectrum agents such as amoxicillin over broad-spectrum alternatives, providing safety-net or delayed prescriptions for mild self-limiting infections like otitis media, adopting short-course therapy of five to seven days for uncomplicated bacterial infections, and engaging families in shared decision-making about watchful waiting. Crucially, the evidence suggests these conservative approaches carry little clinical penalty: short courses and delayed prescriptions do not increase treatment failure rates, yet they can reduce overall antibiotic use by 25 to 30 percent. The WHO’s AWaRe classification, which sorts antibiotics into Access, Watch, and Reserve categories, provides a practical tool for monitoring whether prescribing patterns shift toward narrower agents.

The review catalogs a suite of interventions with demonstrated effectiveness. Continuous professional education combined with audit-and-feedback cycles has been shown to reduce inappropriate prescribing by 20 to 30 percent, though the authors caution that sustained behavior change requires institutional support and leadership engagement rather than one-off training events. Clinical decision support tools embedded in electronic medical records can deliver real-time alerts, weight-based dose calculators, and culture review prompts, offering scalability at the cost of potential alert fatigue and high implementation expenses. Rapid antigen detection tests for streptococcal pharyngitis, influenza, and respiratory syncytial virus help clinicians rule out bacterial causes at the point of care, reducing empirical antibiotic use, though they require investment and training. Local antibiograms—summaries of which pathogens resist which drugs—allow empiric therapy to be tailored to actual resistance patterns, but in Oman these remain more available in hospitals than in community and emergency settings. Multidisciplinary collaboration involving pharmacists, microbiologists, nurses, and infection control specialists rounds out the toolkit, fostering a stewardship culture that bridges inpatient and outpatient care.

Oman’s own experience provides some of the most encouraging data in the review. The Royal Hospital’s antimicrobial stewardship program achieved a dramatic reduction in multidrug-resistant organisms, falling from 2.8 to 0.6 per 1,000 patient-days, while generating annual cost savings estimated at 70,000 to 80,000 US dollars. These results, drawn from a national multicenter initiative, demonstrate that stewardship in the region is not merely aspirational but deliverable with measurable clinical and financial returns. The challenge now, the authors argue, is extending these gains beyond hospital walls into the pediatric emergency departments and primary care clinics where most prescribing actually occurs—and where, notably, no published data yet exists on stewardship outcomes specific to pediatric emergency care in Oman.

The policy scaffolding for such an extension already exists. Oman’s National AMR Action Plan for 2017 to 2022 rests on five pillars: public awareness and education, surveillance and research, rational antimicrobial use, infection prevention and control, and sustainable governance and coordination. These align closely with Oman Vision 2040, the country’s national development blueprint, which prioritizes health system resilience and digital transformation. Yet the review identifies persistent obstacles, including workforce shortages, inconsistent antimicrobial formularies across regions, and limited integration of stewardship data into electronic medical records. Although Oman is classified as a high-income country by the World Bank, the authors observe that some of its healthcare challenges resemble those of upper-middle-income settings, particularly regarding workforce capacity and digital infrastructure—a reminder that income classification alone does not guarantee implementation readiness.

Public behavior emerges as a critical frontier in its own right. In many communities, leftover antibiotics are stored at home, shared among family members, or taken without prescriptions, while parental perceptions that antibiotics accelerate recovery drive demand in clinics and emergency departments. The review highlights educational initiatives that have proven effective at correcting these misconceptions, including school-based programs, pharmacist-led counseling, and national media campaigns. Looking forward, the authors see promise in emerging digital technologies: artificial intelligence-driven clinical decision support, mobile applications, and e-prescription surveillance systems could transform pediatric stewardship, while expanding pharmacists’ roles to include stewardship counseling in outpatient and emergency settings represents an underutilized but impactful strategy. Community engagement through educational posters, digital waiting-room displays, and interactive family tools can reinforce responsible use between clinical encounters.

The review’s ultimate message is one of pragmatic optimism. The evidence base for reducing unnecessary pediatric antibiotic use is mature, the interventions are known, and Oman has already demonstrated that stewardship programs can deliver dramatic reductions in resistance alongside real cost savings. What remains is the harder work of systems integration: embedding evidence-based strategies into the daily workflows of busy emergency departments and primary care clinics, equipping clinicians with diagnostics and decision support, training the workforce in pediatric-specific protocols, and engaging families as partners rather than obstacles. If Oman succeeds in aligning its national AMR policies, Vision 2040 goals, and global best practices across these frontline settings, the authors conclude, it can serve as a regional exemplar for context-sensitive stewardship—and offer a template for the many health systems worldwide grappling with the same quiet crisis in their own waiting rooms.

Subject of Research: Antibiotic stewardship practices in pediatric emergency and primary care settings in Oman

Article Title: Antibiotic stewardship in pediatric emergency and primary care: a narrative review from Oman’s perspective

Article References: Antibiotic stewardship in pediatric emergency and primary care: a narrative review from Oman’s perspective. (n.d.). https://doi.org/10.1007/s44467-025-00006-5

Image Credits: AI Generated

DOI: 10.1007/s44467-025-00006-5

Keywords: antimicrobial stewardship, antimicrobial resistance, pediatrics, emergency medicine, primary care, Oman, antibiotic prescribing, clinical decision support, WHO AWaRe classification, delayed prescriptions, point-of-care diagnostics, public health