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

Alyssa M Pandolfo, Robert Horne, Yogini Jani, Tom W Reader, Natalie Bidad, David Brealey, Virve I Enne, David M Livermore, Vanya Gant, Stephen J Brett, INHALE WP2 Study Group, Julie Barber, Laura Shallcross, Jeronimo Cuesta, Mark Peters, Nigel Klein, Parvez Moondi, Justin O'Grady, Juliet High, Charlotte Russell, David Turner, Suveer Singh, Alyssa M Pandolfo, Robert Horne, Yogini Jani, Tom W Reader, Natalie Bidad, David Brealey, Virve I Enne, David M Livermore, Vanya Gant, Stephen J Brett, INHALE WP2 Study Group, Julie Barber, Laura Shallcross, Jeronimo Cuesta, Mark Peters, Nigel Klein, Parvez Moondi, Justin O'Grady, Juliet High, Charlotte Russell, David Turner, Suveer Singh

Abstract

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.

Keywords: antibiotic management; critical care; decision making; qualitative research.

Conflict of interest statement

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.

Figures

Figure 1
Figure 1
Factors influencing intensive care unit clinicians’ antibiotic prescribing in clinical uncertainty.

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