title: Clinical and social barriers to antimicrobial stewardship in pulmonary medicine: A qualitative study.
abstract: BACKGROUND
  The treatment of pulmonary infections is one of the largest indications for antibiotics in human health care, offering significant potential for antibiotic optimization internationally. This study explores the perspectives of pulmonary clinicians on antibiotic use in hospital pulmonary infections.
  
  
  METHODS
  Twenty-eight pulmonary doctors and nurses from 2 hospitals participated in semi-structured interviews focusing on their experiences of antibiotic use.
  
  
  RESULTS
  Barriers to antibiotic optimization in pulmonary infections were identified. Clinical barriers are as follows. The first is differentiating pneumonia vs chronic obstructive pulmonary disease: differentiating pulmonary diagnoses was reported as challenging, leading to overtreatment. The second is differentiating viral vs bacterial: diagnostic differentiation was perceived to contribute to excess antibiotic use. The third is differentiating colonization vs pathogen: the interpretation of ambiguous results was reported to lead to under- or overprescribing depending on the perspective of the treating team. Social barriers are as follows. The first is the perception of resistance: antibiotic resistance was not perceived as an immediate threat. The second is the perceived value of antibiotic clinical guidelines: there was mistrust in antibiotic guidelines. The third is hospital hierarchies: hierarchical structures had a significant influence on prescribing.
  
  
  CONCLUSIONS
  Substantial barriers to antibiotic optimization in pulmonary infections were identified. To facilitate change in antibiotic use there must be a systematic understanding and interventions to address specific clinical issues. In the case of pulmonary medicine, significant identified issues, such as mistrust in clinical guidelines and diagnostic challenges, need to be addressed.
authors.affiliation: Sunshine Coast University Hospital, Birtinya, QLD, Australia; University of Queensland, QLD, Australia. Electronic address: jennifer.broom@health.qld.gov.au.
authors.forename: Jennifer K
authors.initials: JK
authors.lastname: Broom
authors.affiliation: School of Social Sciences, University of New South Wales, Sydney, NSW, Australia.
authors.forename: Alex F
authors.initials: AF
authors.lastname: Broom
authors.affiliation: School of Social Sciences, University of New South Wales, Sydney, NSW, Australia.
authors.forename: Emma R
authors.initials: ER
authors.lastname: Kirby
authors.affiliation: School of Social Sciences, University of New South Wales, Sydney, NSW, Australia.
authors.forename: Alexandra F
authors.initials: AF
authors.lastname: Gibson
authors.affiliation: Prince of Wales Hospital, NSW, Australia; University of New South Wales, NSW, Australia.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Post
mesh_terms: D000890:Anti-Infective Agents / Q000008:administration & dosage*; D004363:Drug Utilization / Q000592:standards*; D019983:Guideline Adherence; D006801:Humans; D008171:Lung Diseases / Q000188:drug therapy*; D015272:Pulmonary Medicine / Q000592:standards*
chemical_list: D000890:Anti-Infective Agents
keywords: Antibiotic resistance; Antimicrobial stewardship; Guidelines; Pulmonary infection; Qualitative research