Mapping the decision pathways of acute infection management in secondary care among UK medical physicians: a qualitative study

Abstract

BackgroundThe inappropriate use of antimicrobials drives antimicrobial resistance. We conducted a study to map physician decision-making processes for acute infection management in secondary care to identify potential targets for quality improvement interventions.MethodsPhysicians newly qualified to consultant level participated in semi-structured interviews. Interviews were audio recorded and transcribed verbatim for analysis using NVIVO11.0 software. Grounded theory methodology was applied. Analytical categories were created using constant comparison approach to the data and participants were recruited to the study until thematic saturation was reached.ResultsTwenty physicians were interviewed. The decision pathway for the management of acute infections follows a Bayesian-like step-wise approach, with information processed and systematically added to prior assumptions to guide management. The main emerging themes identified as determinants of the decision-making of individual physicians were (1) perceptions of providing ‘optimal’ care for the patient with infection by providing rapid and often intravenous therapy; (2) perceptions that stopping/de-escalating therapy was a senior doctor decision with junior trainees not expected to contribute; and (3) expectation of interactions with local guidelines and microbiology service advice. Feedback on review of junior doctor prescribing decisions was often lacking, causing frustration and confusion on appropriate practice within this cohort.ConclusionInterventions to improve infection management must incorporate mechanisms to promote distribution of responsibility for decisions made. The disparity between expectations of prescribers to start but not review/stop therapy must be urgently addressed with mechanisms to improve communication and feedback to junior prescribers to facilitate their continued development as prudent antimicrobial prescribers.

Barriers to and enablers of implementing antimicrobial stewardship programs in veterinary practices

“…Additional challenges remain in promoting sustainable antimicrobial use in human medicine, requiring behavioral change interventions . In addition, evidence from human medicine indicates that interventions that focus on behavioral change can improve antimicrobial prescribing …”

“…25 In addition, evidence from human medicine indicates that interventions that focus on behavioral change can improve antimicrobial prescribing. 3,[25][26][27] Behavior can be understood to result from interactions among capability, opportunity and motivation 9 and, although the framework has not been specifically assessed for its appropriateness for AMS interventions, it forms a useful platform to interrogate the enablers and barriers in this population of veterinarians. Capability is the physical and psychological skill to institute AMS programs.…”

Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review

“…Therefore, there is a need to incorporate an understanding of local prescribing norms and power dynamics in the design and delivery of context-sensitive education and feedback programmes, including training on teamwork, communication, error awareness and management that addresses the influence of hierarchical teams. 54 , 85 , 105 , 140 , 141 …”

Delivering precision antimicrobial therapy through closed-loop control systems

“…Furthermore, in place of an easily available individualized PK/PD index to guide the assessment of response to therapy, clinicians rely on clinical judgement, physiological parameters, and biochemical markers such as C-reactive protein (CRP) and procalcitonin (PCT) to assess individual patient response. 78 , 79 In particular, CRP, an acute phase protein that is a non-specific marker of inflammation, is one of the most commonly used biomarkers during infection management in clinical practice. 80–82 Despite its wide use in infection management, very little attempt has been made to link it directly to exposure–response using PK/PD modelling.…”