title: An antimicrobial stewardship program initiative: a qualitative study on prescribing practices among hospital doctors.
abstract: BACKGROUND
  Norway has a low, but increasing prevalence of resistance and few antimicrobial stewardship initiatives. When developing stewardship interventions, an understanding of the determinants of antimicrobial prescribing is needed. We report on the first qualitative study investigating factors influencing doctors' antimicrobial prescribing practices in Norwegian hospitals.
  
  
  METHODS
  Qualitative semi-structured interviews were conducted with 15 Norwegian hospital doctors prescribing antimicrobials to adult patients. Interviews were transcribed verbatim and thematic analysis was applied to analyse the data.
  
  
  RESULTS
  Colleagues, in particular infectious disease specialists, microbiology test results and the newly published national guideline on antimicrobials were identified as key factors influencing antimicrobial prescribing practices. Delayed availability was a barrier for the utilization of microbiology test results and increasing clinical experience overrides the influence of the national guideline. Patient assessment, informal training by experienced colleagues, and infectious disease specialists replacing managers in promoting prudent prescribing policies, also influenced prescribing practices.
  
  
  CONCLUSIONS
  This study identified the following contextual factors that need to be addressed when developing antimicrobial stewardship programs in Norway: a common work practice for seeking collegial advice, logistics of microbiology test results, and formal leadership and systematic training on prudence. Other countries initiating stewardship programmes may benefit from performing a similar mapping of facilitators and barriers, to identify important stakeholders and organisational obstacles, before developing sustainable and tailored antimicrobial stewardship interventions.
authors.affiliation: Norwegian Advisory Unit on Antibiotic use in hospitals, Department of Research and Development, Haukeland University Hospital, 5021 Bergen, Norway.
authors.forename: Brita
authors.initials: B
authors.lastname: Skodvin
authors.affiliation: Department of Health Studies, University of Stavanger, 4036 Stavanger, Norway.
authors.forename: Karina
authors.initials: K
authors.lastname: Aase
authors.affiliation: NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Du Cane Road, London, W12 0NN UK.
authors.forename: Esmita
authors.initials: E
authors.lastname: Charani
authors.affiliation: NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Du Cane Road, London, W12 0NN UK.
authors.forename: Alison
authors.initials: A
authors.lastname: Holmes
authors.affiliation: Norwegian Advisory Unit on Antibiotic use in hospitals, Department of Research and Development, Haukeland University Hospital, 5021 Bergen, Norway.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Smith
keywords: Antimicrobial guideline; Antimicrobial resistance; Antimicrobial use; Hospital doctors; Prescription practices; Qualitative research