Understanding decisions about antibiotic prescribing in ICU: an application of the Necessity Concerns Framework.

Autor:	Pandolfo AM; Centre for Behavioural Medicine, University College London, London, UK., Horne R; Centre for Behavioural Medicine, University College London, London, UK r.horne@ucl.ac.uk., Jani Y; UCLH-UCL Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK., Reader TW; Department of Psychological and Behavioural Science, London School of Economics and Political Science, London, UK., Bidad N; Centre for Behavioural Medicine, University College London, London, UK., Brealey D; Division of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK., Enne VI; Division of Infection and Immunity, University College London, London, UK., Livermore DM; Norwich Medical School, University of East Anglia, Norwich, UK., Gant V; Department of Medical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK., Brett SJ; Department of Surgery and Cancer, Imperial College London, London, UK.
Jazyk:	angličtina
Zdroj:	BMJ quality & safety [BMJ Qual Saf] 2022 Mar; Vol. 31 (3), pp. 199-210. Date of Electronic Publication: 2021 Jun 07.
DOI:	10.1136/bmjqs-2020-012479
Abstrakt:	Background: Antibiotics are extensively prescribed in intensive care units (ICUs), yet little is known about how antibiotic-related decisions are made in this setting. We explored how beliefs, perceptions and contextual factors influenced ICU clinicians' antibiotic prescribing. Methods: We conducted 4 focus groups and 34 semistructured interviews with clinicians involved in antibiotic prescribing in four English ICUs. Focus groups explored factors influencing prescribing, whereas interviews examined decision-making processes using two clinical vignettes. Data were analysed using thematic analysis, applying the Necessity Concerns Framework. Results: Clinicians' antibiotic decisions were influenced by their judgement of the necessity for prescribing/not prescribing, relative to their concerns about potential adverse consequences. Antibiotic necessity perceptions were strongly influenced by beliefs that antibiotics would protect patients from deterioration and themselves from the ethical and legal consequences of undertreatment. Clinicians also reported concerns about prescribing antibiotics. These generally centred on antimicrobial resistance; however, protecting the individual patient was prioritised over these societal concerns. Few participants identified antibiotic toxicity concerns as a key influencer. Clinical uncertainty often complicated balancing antibiotic necessity against concerns. Decisions to start or continue antibiotics often represented 'erring on the side of caution' as a protective response in uncertainty. This approach was reinforced by previous experiences of negative consequences ('being burnt') which motivated prescribing 'just in case' of an infection. Prescribing decisions were also context-dependent, exemplified by a lower perceived threshold to prescribe antibiotics out-of-hours, input from external team members and local prescribing norms. Conclusion: Efforts to improve antibiotic stewardship should consider clinicians' desire to protect with a prescription. Rapid molecular microbiology, with appropriate communication, may diminish clinicians' fears of not prescribing or of using narrower-spectrum antibiotics. Competing Interests: Competing interests: VIE reports personal fees and non-financial support from bioMerieux, personal fees from Curetis and non-financial support from Oxford Nanopore Technologies, outside the submitted work. DML reports personal fees from Accelerate, Allecra, Antabio, Astellas, Beckman Coulter, bioMerieux, Cepheid, Centauri, Entasis, Johnson & Johnson, Meiji, Melinta, Menarini, Mutabilis, Nordic, ParaPharm, QPEX, Roche, Shionogi, Tetraphase, Wockhardt, Zambon, Cardiome and Eumedica. He also reports grants and personal fees from VenatoRx; personal fees and other (shareholder) from GlaxoSmithKline; personal fees and other (stock options) from TAZ; grants, personal fees and other (shareholder) from Merck/MSD and Pfizer; and other (shareholder) from Perkin Elmer and Dechra. All are outside the submitted work. (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
Databáze:	MEDLINE
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