Critical points in the pathway of antibiotic prescribing in a children's hospital: the Antibiotic Mapping of Prescribing (ABMAP) study

The World Health Organization has identified antimicrobial resistance (AMR) as one of the most significant global risks facing modern medicine. Interventions to improve antibiotic prescribing have so far had limited impact. To understand the barriers to effective antibiotic prescribing. Mixed methodologies were used to investigate prescribing behaviours to identify the critical points in the antibiotic prescribing pathway for hospital inpatients. We assessed knowledge, experience or empowerment of prescribers, organizational factors, and use of the laboratory. Phase 1 was an online survey to map barriers and facilitators to antibiotic prescribing (56 participants). Phase 2 consisted of focus groups and interviews to gain more understanding of prescribing behaviours (10 participants). Phase 3 was an online survey to obtain opinions on possible solutions (22 participants). Barriers to prescribing were: laboratory factors 71.6%, resource issues 40%, time constraints 17.5%, pressure from others 52%. Ninety-three percent of prescribers were concerned about AMR. In three scenarios only 9% were confident not to prescribe antibiotics for a patient without bacterial infection; 53% would prescribe unnecessarily broad-spectrum antibiotics for pneumonia. Only 5% would de-escalate antibiotics in a microbiologically confirmed bacteraemia. Despite concerns about AMR, prescribers did not perceive that continuing antibiotics for individual patients might promote resistance. Prescribers were unwilling to change antibiotics out of hours and reported that they preferred professional support for antibiotic prescribing. There was a marked disparity between prescribers, self-reporting of prescribing behaviour and responses to clinical scenarios. It was not clear whether training alone would change behaviours. Prescribers desired a directive mechanism to support antibiotic prescribing and stewardship.