Stewart Sarah-Jane F, Pandolfo Alyssa M, Jani Yogini, Moon Zoe, Brealey David, Enne Virve I, Livermore David M, Gant Vanya, Brett Stephen J, Horne Rob
School of Pharmacy, University College London, London, United Kingdom.
UCLH-UCL Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, United Kingdom.
Antimicrob Agents Chemother. 2025 Mar 5;69(3):e0115624. doi: 10.1128/aac.01156-24. Epub 2025 Feb 5.
Rapid molecular diagnostic tests improve antimicrobial stewardship (AMS) by facilitating earlier refinement of antimicrobial therapy. The INHALE trial tested the application of the BioFire FilmArray Pneumonia Panel (Pneumonia Panel) for antibiotic prescribing for hospital-acquired and ventilator-associated pneumonias (HAP/VAP) in UK intensive care units (ICUs). We report a behavioral study embedded within the INHALE trial examining clinicians' perceptions of using these tests. Semi-structured interviews were conducted with 20 ICU clinicians after using the Pneumonia Panel to manage suspected HAP/VAP. Thematic analysis identified factors reinforcing perceptions of the necessity to modify antibiotic prescribing in accordance with test results and doubts/concerns about doing so. While most acknowledged the importance of AMS, the test's impact on prescribing decisions was limited. Concerns about potential consequences of undertreatment to the patient and prescriber were often more salient than AMS, sometimes leading to "just-in-case" antibiotic prescriptions. Test results indicating a broad-spectrum antibiotic were unnecessary often failed to influence clinicians to avoid an initial prescription or de-escalate antibiotics early as they considered their use to be necessary to protect the patient and themselves, "erring on the side of caution." Some clinicians described cases where antibiotics would be prescribed for a sick patient regardless of test results because, in their opinion, it fits with the clinical picture-"treating the patient, not the result." Our findings illustrate a tension between prescribing guidelines and clinicians' "mindlines," characterized by previous experiences. This highlights the need for a "technology plus" approach, recognizing the challenges clinicians face when applying technological solutions to patient care.IMPORTANCERapid molecular diagnostic tests for pathogens and resistance genes may improve antibiotic-prescribing decisions and stewardship. However, clinicians' desire to protect their patients with antibiotics often overrides more distal concerns about possible resistance selection, limiting the application of these tests in practice. Findings underscore the challenge of changing prescribing decisions based on technical results or guidelines, highlighting factors such as clinicians' previous experience and "knowledge in practice" as more proximal drivers of these decisions. Implementation strategies for technological solutions to antimicrobial resistance must be "behaviorally intelligent," recognizing the challenges facing clinicians when making "life or death" prescribing decisions.CLINICAL TRIALSThis study is registered with ISRCTN as ISRCTN16483855.
快速分子诊断测试通过促进抗菌治疗的早期优化来改善抗菌药物管理（AMS）。INHALE试验测试了BioFire FilmArray肺炎检测板（肺炎检测板）在英国重症监护病房（ICU）中用于医院获得性肺炎和呼吸机相关性肺炎（HAP/VAP）抗生素处方的应用情况。我们报告了一项纳入INHALE试验的行为研究，该研究考察了临床医生对使用这些检测的看法。在使用肺炎检测板管理疑似HAP/VAP后，对20名ICU临床医生进行了半结构化访谈。主题分析确定了强化根据检测结果调整抗生素处方必要性的认知的因素，以及对此做法的疑虑/担忧。虽然大多数人承认AMS的重要性，但该检测对处方决策的影响有限。对患者和开处方者治疗不足潜在后果的担忧往往比AMS更突出，有时会导致“以防万一”的抗生素处方。检测结果表明无需使用广谱抗生素时，往往无法影响临床医生避免初始处方或尽早降低抗生素级别，因为他们认为使用抗生素对保护患者和自身是必要 的，要“宁可谨慎过头”。一些临床医生描述了无论检测结果如何都会给患病患者开抗生素的情况，因为在他们看来，这符合临床表现——“治疗患者，而非检测结果”。我们的研究结果表明了处方指南与临床医生以既往经验为特征的“思维路线”之间的矛盾。这凸显了采取“技术 +”方法的必要性，认识到临床医生在将技术解决方案应用于患者护理时所面临的挑战。
重要性
针对病原体和耐药基因的快速分子诊断测试可能会改善抗生素处方决策和管理。然而，临床医生用抗生素保护患者的愿望往往压倒了对可能的耐药性选择的更长远担忧，限制了这些检测在实际中的应用。研究结果强调了根据技术结果或指南改变处方决策的挑战，突出了临床医生既往经验和“实践中的知识”等因素作为这些决策更直接驱动因素的作用。针对抗菌药物耐药性的技术解决方案的实施策略必须“具备行为智慧”，认识到临床医生在做出“生死攸关”的处方决策时所面临的挑战。
临床试验
本研究已在ISRCTN注册，注册号为ISRCTN16483855。
