Schouten Jeroen A, Hulscher Marlies E J L, Natsch Stephanie, Kullberg Bart-Jan, van der Meer Jos W M, Grol Richard P T M
Centre for Quality of Care Research, Radboud University Medical Centre, Nijmegen, The Netherlands.
Qual Saf Health Care. 2007 Apr;16(2):143-9. doi: 10.1136/qshc.2005.017327.
Physician adherence to key recommendations of guidelines for community-acquired pneumonia (CAP) is often not optimal. A better understanding of factors influencing optimal performance is needed to plan effective change.
The authors used semistructured interviews with care providers in three Dutch medium-sized hospitals to qualitatively study and understand barriers to appropriate antibiotic use in patients with CAP. They discussed recommendations about the prescription of empirical antibiotic therapy that adheres to the guidelines, timely administration of antibiotics, adjusting antibiotic dosage to accommodate decreased renal function, switching and streamlining therapy, and blood and sputum culturing. The authors then classified the barriers each recommendation faced into categories using a conceptual framework (Cabana).
Eighteen interviews were performed with residents and specialists in pulmonology and internal medicine, with medical microbiologists and a clinical pharmacist. Two additional multidisciplinary small group interviews which included nurses were performed. Each guideline recommendation elicited a different type of barrier. Regarding the choice of guideline-adherent empirical therapy, treating physicians said that they worried about patient outcome when prescribing narrow-spectrum antibiotic therapy. Regarding the timeliness of antibiotic administration, barriers such as conflicting guidelines and organisational factors (for example, delayed laboratory results, antibiotics not directly available, lack of time) were reported. Not streamlining therapy after culture results became available was thought to be due to the physicians' attitude of "never change a winning team".
Efforts to improve the use of antibiotics for patients with CAP should consider the range of barriers that care providers face. Each recommendation meets its own barriers. Interventions to improve adherence should be tailored to these factors.
医生对社区获得性肺炎（CAP）指南关键建议的遵循情况往往不尽如人意。需要更好地了解影响最佳表现的因素，以规划有效的变革。
作者对荷兰三家中型医院的医护人员进行了半结构化访谈，以定性研究和了解CAP患者合理使用抗生素的障碍。他们讨论了关于遵循指南进行经验性抗生素治疗的处方、抗生素的及时使用、根据肾功能下降调整抗生素剂量、更换和简化治疗以及血液和痰液培养的建议。然后，作者使用一个概念框架（卡巴纳）将每项建议所面临的障碍分类。
对呼吸内科、内科的住院医师和专科医生、医学微生物学家和临床药剂师进行了18次访谈。另外还进行了两次包括护士在内的多学科小组访谈。每项指南建议都引发了不同类型的障碍。关于选择遵循指南的经验性治疗，主治医生表示，他们在开具窄谱抗生素治疗时担心患者的预后。关于抗生素给药的及时性，报告了一些障碍，如相互冲突的指南和组织因素（例如，实验室结果延迟、抗生素无法直接获得、时间不足）。在培养结果出来后不简化治疗被认为是由于医生“从不更换获胜团队”的态度。
改善CAP患者抗生素使用的努力应考虑医护人员面临的一系列障碍。每项建议都有其自身的障碍。改善遵循情况的干预措施应针对这些因素进行调整。
