Barriers to guideline-concordant antibiotic use among inpatient physicians: A case vignette qualitative study

Abstract

BACKGROUND: Greater adherence to antibiotic-prescribing guidelines may promote more judicious antibiotic use, which could benefit individual patients and society at large. OBJECTIVE: To assess physician knowledge and acceptance of antibiotic-prescribing guidelines through the use of case vignettes. DESIGN: We conducted semistructured interviews with 30 inpatient physicians. Participants were asked to respond to 3 hypothetical case vignettes: (1) a skin and soft tissue infection (SSTI), (2) suspected hospital-acquired pneumonia (HAP), and (3) asymptomatic bacteriuria (ASB). All participants received feedback according to guidelines from the Infectious Diseases Society of America (IDSA) and were asked to discuss their level of comfort with following these guidelines. SETTING: Two acute care teaching hospitals for adult patients. INTERVENTION: None. MEASUREMENTS: Data from transcribed interviews were analyzed using emergent thematic analysis. RESULTS: Participants were receptive to guidelines and believed they were useful. However, participants' responses to the case vignettes demonstrated that IDSA guideline recommendations were not routinely followed for SSTI, HAP, and ASB. We identified 3 barriers to guideline-concordant care: (1) physicians' lack of awareness of specific guideline recommendations; (2) tension between adhering to guidelines and the desire to individualize patient care; and (3) skepticism of certain guideline recommendations. CONCLUSIONS: Case vignettes may be useful tools to assess physician knowledge and acceptance of antibiotic-prescribing guidelines. Using case vignettes, we identified 3 barriers to following IDSA guidelines. Efforts to improve guideline-concordant antibiotic prescribing should focus on reducing such barriers at the local level.