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

Abstract

BackgroundAntibiotics 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.MethodsWe 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.ResultsClinicians’ 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.ConclusionEfforts 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.

Instant Gratification and Overtreating to Be Safe: Perceptions of U.S. Intensive Care Unit Pharmacists and Residents on Antimicrobial Stewardship

“…Primarily, if microbes such as bacteria are seen as threatening, a strong impetus to protect exists in medical care around infection. As a safety issue, the use of antimicrobials as a “magic bullet” or “just in case”-prescribing can thus easily lead to overtreatment [ 15 , 16 , 17 ]. The concept of the magic bullet was famously used by biochemist Paul Ehrlich to describe Salvarsan 606′s effect on syphilis and became a commonly utilized frame for medicinal use in human populations [ 18 , 19 ].…”

WHY STOP? Quantifying Cognitive-Behavioural factors that influence the impact of PCR-POCT results on antibiotic cessation in ICU

“…The most commonly-selected reason in the present study was that "the test is unnecessary in this case", indicating conviction in their decision. Prior work has recognised lack of trust in the validity of POCT amongst clinicians [22,23]; presently, only a minority of POCT-rejectors indicated lack of trust, but this may be due to our deliberate presentation of the POCT as reliable. Whatever clinicians' reasons for rejecting POCT, unregulated POCT without appropriate guidance will reduce its utility.…”

“…The necessity concerns framework (NCF) details the bene t-risk relationship to treatment decision [24]. In a previous study (also using vignette-based interviews about nosocomial infection), ICU clinicians described 'erring on the side of caution'; clinicians viewed antibiotics' necessity (i.e., protection for their patients and themselves) as outweighing concerns about antibiotic toxicity and AMR [25].…”

The value, challenges and practical considerations of conducting qualitative research on antimicrobial stewardship in primary care

“…Combining inductive and deductive approaches can also be useful in order to explore views while in addition drawing on a relevant theory. 60 , 61 For example, Courtenay et al 60 focused on understanding influences on antibiotic prescribing by nurses and pharmacist prescribers; they inductively coded interviews but then mapped these codes onto an existing theory, thus allowing a systematic examination of the influences.…”