Leveraging sociological systems theory: integrating transformational leadership and social capital to enhance quality of care - an exploratory longitudinal study of German hospitals.

Antimicrobial resistance (AMR) poses a major threat to global health, and it is estimated that by 2050, approximately two million people could die from drug‐resistant infections globally per year (Naghavi et al., ). Overprescription and inappropriate use of antibiotics are major contributors to the global increase in AMR (Cassini et al., ; Hofer, ). Appropriate prescribing decisions are typically defined as the right drug administered at the right time, in the right dose, for the right length of time (Dryden et al., ). Hence, prescribing antibiotics is considered inappropriate when, per established guidelines, the use of other or no antimicrobial agents is recommended. For example, prescribing antibiotics to treat viral infections is considered inappropriate (Sijbom et al., ). Delayed antibiotic prescribing is a recommended strategy to reduce inappropriate antibiotic use, particularly in cases where it is uncertain whether the infection is viral or bacterial (Spurling et al., ). By encouraging watchful waiting, that is, instructing patients to wait and monitor their symptoms before initiating antibiotic treatment, delayed prescribing has been demonstrated to reduce antibiotic use in primary care settings (Little et al., ; Spurling et al., ; Stuart et al., ). Therefore, it offers an effective compromise between immediate prescribing and withholding treatment altogether. Moreover, delayed prescribing can lead to a shorter symptom duration than withholding antibiotics (de la Poza Abad et al., ) and can foster trust in the doctor–patient relationship, because it empowers patients to actively participate in treatment decisions (Dallas et al., ). However, the effectiveness of delayed prescribing is often undermined by low patient adherence: many patients fill and use the antibiotic prescription immediately, even when advised to delay treatment. A systematic review found that nearly two thirds of patients initiated antibiotic use on the same day they received a delayed prescription (Francis et al., ), and recent observational data report similarly high rates of immediate use (Llor et al., ). This immediate use undermines the intention of delayed prescribing and can lead to unnecessary antibiotic consumption, exposing patients to potential side effects without clinical benefit (Rowe & Linder, ). Additionally, unnecessary antibiotic use increases AMR. Hence, there is an imbalance between short‐term individual gain and long‐term collective public health outcomes in the delayed prescribing approach, whereby patients may interpret the act of receiving a prescription as a cue for immediate use. To mitigate this, delayed prescribing should be embedded within a safety netting framework (Jones et al., ). This includes clear communication about clinical uncertainty, explicit instructions about when to initiate antibiotics and guidance on when to seek follow‐up care. Therefore, to support more appropriate antibiotic use and increase the effectiveness of delayed prescribing for antibiotic stewardship, complementary communication interventions are necessary to help patients better understand the rationale behind delayed prescribing and empower them to make informed decisions about if and when to start antibiotic treatment. Understanding why patients often fail to adhere to watchful waiting reveals barriers that these communication interventions must address.