title: Understanding the determinants of antimicrobial prescribing within hospitals: the role of "prescribing etiquette".
abstract: BACKGROUND
  There is limited knowledge of the key determinants of antimicrobial prescribing behavior (APB) in hospitals. An understanding of these determinants is required for the successful design, adoption, and implementation of quality improvement interventions in antimicrobial stewardship programs.
  
  
  METHODS
  Qualitative semistructured interviews were conducted with doctors (n = 10), pharmacists (n = 10), and nurses and midwives (n = 19) in 4 hospitals in London. Interviews were conducted until thematic saturation was reached. Thematic analysis was applied to the data to identify the key determinants of antimicrobial prescribing behaviors.
  
  
  RESULTS
  The APB of healthcare professionals is governed by a set of cultural rules. Antimicrobial prescribing is performed in an environment where the behavior of clinical leaders or seniors influences practice of junior doctors. Senior doctors consider themselves exempt from following policy and practice within a culture of perceived autonomous decision making that relies more on personal knowledge and experience than formal policy. Prescribers identify with the clinical groups in which they work and adjust their APB according to the prevailing practice within these groups. A culture of "noninterference" in the antimicrobial prescribing practice of peers prevents intervention into prescribing of colleagues. These sets of cultural rules demonstrate the existence of a "prescribing etiquette," which dominates the APB of healthcare professionals. Prescribing etiquette creates an environment in which professional hierarchy and clinical groups act as key determinants of APB.
  
  
  CONCLUSIONS
  To influence the antimicrobial prescribing of individual healthcare professionals, interventions need to address prescribing etiquette and use clinical leadership within existing clinical groups to influence practice.
authors.affiliation: The National Centre for Infection Prevention and Management, Imperial College London, 2nd Floor, Hammersmith House, Du Cane Road, London W12 OHS, UK. e.charani@imperial.ac.uk
authors.forename: E
authors.initials: E
authors.lastname: Charani
authors.forename: E
authors.initials: E
authors.lastname: Castro-Sanchez
authors.forename: N
authors.initials: N
authors.lastname: Sevdalis
authors.forename: Y
authors.initials: Y
authors.lastname: Kyratsis
authors.forename: L
authors.initials: L
authors.lastname: Drumright
authors.forename: N
authors.initials: N
authors.lastname: Shah
authors.forename: A
authors.initials: A
authors.lastname: Holmes
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D011307:Drug Prescriptions / Q000592:standards*; D006282:Health Personnel; D006302:Health Services Research; D006761:Hospitals; D006801:Humans; D007407:Interviews as Topic; D008131:London; D011361:Professional Competence / Q000592:standards / Q000706:statistics & numerical data
chemical_list: D000900:Anti-Bacterial Agents
keywords: antimicrobial prescribing; prescribing behavior; prescribing etiquette