Table 3. Opportunity-Related Salient Barriers or Facilitators to Antibiotic Stewardship in Acne Treatment.

Domain and theme	Representative quote (participant No., male/female [M/F], degree, role)
Environmental context and resources
iPLEDGE22 barriers	“Doxycycline takes seconds to renew. Isotretinoin takes, depending on circumstances, hours sitting on iPLEDGE.” (12, M, MD, dermatology attending physician) “When you present somebody with a consent form to take a drug, [they think], ‘okay this is really serious.’ And it is, but we don’t have them sign a consent form for some of the other drugs that we use which are equally serious, like methotrexate, for instance.” (16, F, MD, dermatology attending physician)
Absence of effective system for measuring progress	“…there’s no flagging feature. There’s no buddy. We don’t have clinical pharmacists looking over us to kind of give us warnings or notifications.” (4, M, MD, dermatology attending physician) “I think that [we need] more systems in place to be able to see the prescriptions that patients received in the past, something that’s user-friendly and can easily pull from multiple different pharmacies...” (14, F, MD, dermatology attending physician)
Need for effective nonantibiotic alternative therapies	“Patients that flare as soon as they come off, basically, or I try something different, they don’t tolerate it and just want to go back to the antibiotic. Those are things that would make it difficult to follow the [guidelines].” (3, F, MD, dermatology attending physician) “It’s challenging because you have to find something else that works, and something that is deployable that people will adhere to and accept that works as well or better. That’s the limitation here. Antibiotics are cheap; they’re easy to take. They’re well tolerated by individual patients, and they work. The alternatives are either potentially more expensive, more difficult to deploy, or have just as many or more concerns associated with them.” (12, M, MD, dermatology attending physician)
Refill protocols	“If [patients] don’t have their follow-up or she’s not scheduled or something happens, you have nurse protocols that allow someone else to refill it without knowing the overall plan or following the guidelines.” (3, F, MD, dermatology attending physician)
Limited capacity for follow-up	“… let’s say you have acne…I think you could probably be done [with antibiotics] in a month. But I don’t have access to see you in a month. So, sometimes I think there is an incentive to give you a longer dose because of that access to care issue.” (8, M, MD, dermatology attending physician)
Financial considerations	“I think [payers] probably would prefer to pay for an antibiotic than they would isotretinoin and the topicals. The cost of some of the [prescription] topicals are quite extreme now.” (16, F, MD, dermatology attending physician)
Social influences
Patient satisfaction	“…[limiting antibiotic use] conflicts with my goal of, I like being well-liked by my patients. I like it when they give me positive reviews...” (14, F, MD, dermatology attending physician) “I think there’s a balance between doing what’s recommended by societies and also based on what patients want and making the patients happier, not necessarily if it’s the most kosher thing to do.” (10, M, MD, dermatology resident)
Other clinicians’ prescribing practices	“If that practitioner sticks to the 3-month rule, then the patient simply goes to a different practitioner, gets antibiotics, and then they’re actually getting more antibiotics. They’re starting over and over and what’s worse than being on an antibiotic continuously is starting and stopping an antibiotic and developing resistance.” (5, M, MD, dermatology attending physician)