Background: Antimicrobial stewardship (AMS) is a key issue in intensive care units (ICUs) where antibiotics are widely prescribed for complex patients. However, there is limited research examining how antibiotic prescribing decisions are made and how antimicrobial resistance (AMR) concerns impact decision-making in this context. INHALE is a comprehensive research programme exploring the influence of molecular diagnostics on prescribing for hospital acquired pneumonia (HAP) in ICU. This study explored how prescriber perceptions and contextual factors influence antibiotic prescribing decisions in ICUs, prior to implementation of molecular tests.
Materials/methods: Four focus groups and 34 vignette-based interviews were conducted with clinicians involved in antibiotic prescribing in four UK ICUs. Focus groups explored clinicians’ perceptions of factors influencing their prescribing decisions and semi-structured interviews explored decision-making processes using two clinical vignettes in the context of HAP. Data were analysed using inductive thematic analysis.
Results: Prescriber perceptions were key to decision-making. Most clinicians balanced the societal risks of AMR against the needs of the individual patient, with the latter generally given precedence. In situations of doubt, the default was to prescribe antibiotics on the basis that the antibiotics might prevent patient mortality, with clinicians viewing prescribing as more defensible than not prescribing. The side-effects of antibiotics were rarely mentioned. Clinicians were aware of AMR and strove to withhold potentially unnecessary antibiotics where possible. This aim was counter-balanced by their previous experiences of negative consequences, which motivated the prescribing of antibiotics ‘just in case’ of an infection.
Clinicians’ perceptions interacted with the prescribing context. Examples include a lower perceived threshold to prescribe antibiotics out of hours, the influence of input from non-ICU team members, as well as antibiotic prescribing norms and varied adherence to guideline recommendations across ICUs.
Conclusions: When making prescribing decisions, clinicians’ understandable fear of undertreating possible infection and worsening outcomes is often in direct conflict with AMS aspirations. Prescribers seem to be driven by perceived negative consequences for patients and themselves over more distal issues of AMR. Evidence-based support from faster and more effective diagnostics may help reconcile these competing priorities by allowing for earlier antibiotic de-escalation and refinement.