Emergency Department Clinicians’ Needs for User-Centered Antibiotic Guideline: Insights from a Focus Group Interview

Abstract

Background

Institution-specific antibiotic guidelines are core components of effective antibiotic stewardship programs; however, their practical use in emergency departments (EDs), where empirical antibiotic decisions are made under time pressure and diagnostic uncertainty, remains limited. This study explored ED clinicians’ perspectives on antibiotic prescribing and identified key elements for developing ED-specific antibiotic guidelines.

Materials and Methods

Focus group interviews were conducted between October 12 and October 26, 2022, at four tertiary hospitals in Korea. A total of 16 physicians participating directly in ED antibiotic prescribing were enrolled including Emergency medicine and internal medicine physicians. Interviews were recorded, transcribed and analyzed using thematic analysis by two infectious disease specialists.

Results

Clinicians reported substantial challenges in prescribing empirical antibiotics, including diagnostic uncertainty, complex clinical scenarios, and practical prescribing issues such as dosing and administration details. Antibiotic decision-making was influenced by patient-related factors and institutional culture, including department-specific prescribing preferences. Existing antibiotic guidelines were infrequently used due to poor usability and limited applicability to real-world ED practice. Participants emphasized the need for concise, algorithm-based guidelines incorporating practical prescribing information and better integration into clinical workflows.

Conclusion

ED clinicians perceived existing antibiotic guidelines as poorly aligned with ED practice. User-centered, institution-specific antibiotic guidelines may enhance applicability and support appropriate empirical antibiotic prescribing in the ED.

Graphical Abstract

Introduction

The emergency department (ED) is often the first point of contact for patients with acute infectious diseases requiring antibiotic therapy, including sepsis, and the place where antibiotics are frequently prescribed [1]. In particular, early administration of appropriate antibiotics is strongly associated with improved outcomes in patients with severe infections, underscoring the critical role of initial antibiotic decision-making in the ED [2]. However, ED is also characterized by substantial time constraints, limited availability of diagnostic test results at initial presentation, and diagnostic uncertainty. In this environment, clinicians are often required to initiate empirical antibiotic therapy before a definitive infectious diagnosis can be established, making appropriate antibiotic selection particularly challenging [3]. Indeed, inappropriate antibiotic prescription has been reported to occur in a substantial proportion of ED encounters [4,5].

Antibiotic stewardship programs (ASPs) have been established as key strategies to promote appropriate antibiotic use and to mitigate the emergence of antimicrobial resistance [6]. In addition to core interventions such as prospective audit and feedback and preauthorization of antimicrobial use, the importance of implementing institution-specific antibiotic guidelines is emphasized as a central component of effective stewardship programs [6,7]. However, most existing antibiotic guidelines are designed as comprehensive reference documents to single infection, rather than tools optimized for rapid decision-making in acute care settings. This raises an important question as to whether current guidelines adequately support antibiotic decision-making process in the time-pressured environment of the ED.

In Korea, the availability of institution-specific empirical antibiotic guidelines for major infectious diseases remains limited. A nationwide survey conducted in 2020 reported that only 12.9% of hospitals had such guidelines, even among tertiary hospitals [8]. While ED-specific antibiotic stewardship efforts have gained increasing attention internationally, limited evidence is available regarding how ED clinicians perceive, interpret, and practically use antibiotic guidelines in routine clinical settings in Korea [9,10]. Therefore, this study aimed to explore ED clinicians’ perceived needs regarding antibiotic prescribing guidelines and to identify factors that may facilitate their practical use through focus group interviews (FGIs).

Materials and Methods

1. Study design and participants

The FGIs were conducted between October 12 and October 26, 2022, at four tertiary hospitals in Korea: Hanyang University Seoul Hospital, Yongin Severance Hospital, National Health Insurance Service Ilsan Hospital, and Kyungpook National University Chilgok Hospital. At each institution, one infectious diseases specialist, who was trained in qualitative interview methodologies to ensure clinical relevance and analytic rigor, conducted in-person interviews with four physicians who were directly involved in antibiotic prescribing in the emergency department.

Participants were selected via purposive sampling to ensure diverse clinical perspectives. Despite differences in training levels, all participants shared a similar, direct role in frontline empiric antibiotic decision-making and order entry in the ED. To mitigate potential hierarchical bias within the focus groups, interviews were conducted in a supportive, non-punitive environment where junior clinicians (residents and fellows) were explicitly encouraged to share their experiences first, ensuring that power dynamics did not suppress open discussion. As a result, a total of 16 physicians participated in the FGIs, including emergency medicine attendings (n=6), one emergency medicine fellow, emergency medicine residents (n=4), one infectious diseases fellow, and internal medicine residents (n=4) (Table 1).

Table 1. Demographic and characteristics of the study participants.

Characteristic	Category	N=16 (%)
Department	Emergency medicine	11 (68.8)
	Internal medicine / infectious disease	5 (31.3)
Position	Attending physician, emergency medicine	6 (37.5)
	Fellow (emergency medicine: 1, infectious diseases: 1)	2 (12.5)
	Resident (emergency medicine: 4, internal medicine: 4)	8 (50.0)
Clinical experience	<4 years	5 (31.3)
	4–6 years	4 (25.0)
	≥7 years	7 (43.8)
Baseline guideline awareness	Aware of existing guidelines	11 (68.8)
	Unaware of existing guidelines	5 (31.2)

2. Ethics statement

The study protocol was approved by the Institutional Review Board (IRB) of Hanyang University Hospital (IRB No. 2022-10-001). All methods were performed in accordance with these guidelines and regulations.

3. Focus group interviews and data analysis

Each interview session lasted approximately 40–60 minutes and was guided by a semi-structured questionnaire, the contents of which are summarized in Table 2. The semi-structured interview guide was initially drafted based on a literature review of global ASP implementation barriers and the questions were subsequently refined and validated through discussions within the research group. All interviews were recorded for subsequent analysis.

Table 2. Structured focus group interview guide questions.

Domain	Interview questions
Challenges in prescribing empirical antibiotics in the ED	Q1. What aspects are most challenging when deciding whether to prescribe antibiotics for patients with suspected infection in ED?
	Q2. What difficulties do you encounter when selecting and prescribing antibiotics after deciding to administer antibiotics?
Antibiotic decision-making in the ED	Q1. What factors most strongly influence when prescribing antibiotics in the ED?
	Q2. What resources do you commonly consult when prescribing antibiotics?
Awareness of existing antibiotic guidelines	Q1. Are you aware of guidelines for common infections? (e.g., urinary tract infection, community-acquired pneumonia, skin and soft tissue infection, gastrointestinal infection)
	Q2. Do you apply these guidelines in actual practice, and if not, what are the reasons?
Facilitators of appropriate empirical antibiotic use in the ED	Q1. What do you think are limitations in prescribing appropriate empirical antibiotics?
	Q2. What kinds of improvement would help promote more appropriate antibiotic use?
Preferred format of antibiotic guidelines	Q1. What difficulties do you experience when using existing antibiotic guidelines in practice?
	Q2. What elements should be included or excluded to improve real-world applicability in the ED?

ED, emergency department.

The recorded interviews were transcribed verbatim and analyzed using thematic analysis. Two infectious disease specialists independently reviewed and coded the transcripts into themes and subthemes. Themes were identified inductively based on recurrent patterns in the data. Discrepancies in interpretation were discussed in a consensus meeting, during which the analytical framework was refined. This process continued until full agreement was reached among the researchers. To ensure transparent and comprehensive reporting of the qualitative data, the final manuscript was reviewed and aligned with the core elements of the consolidated criteria for reporting qualitative research guidelines.

Results

1. Contextual challenges in empirical antibiotic prescribing in the ED

Among the 16 participants, 11 (68.8%) reported being aware of existing guidelines, while 5 (31.3%), predominantly junior residents, were completely unaware of them (Table 1). Through the FGIs, ED clinicians described substantial challenges when prescribing empirical antibiotics (Table 3). Participants described significant diagnostic uncertainty at initial presentation, as discrepancies between early clinical symptoms and limited laboratory data often made it difficult to identify whether infection really exists. In particular, internal medicine clinicians focused heavily on this diagnostic differentiation, noting difficulties in distinguishing true bacterial infections from non-infectious inflammation or cancer-related fevers. Even after determining to initiate antibiotic therapy, clinicians reported difficulties in selecting appropriate agents across diverse and ambiguous clinical scenarios, as well as practical prescribing issues (Table 3). These pragmatic knowledge gaps—including real-time dose adjustment in patients with renal dysfunction, selection of appropriate mixed fluid, and determination of infusion rates—were identified as major barriers primarily by junior clinicians with six or fewer years of experience. Despite these challenges, decisions on antibiotic treatment had to be made promptly. Clinicians relied primarily on patient-related factors such as severity of illness, patients’ comorbidities, and prior antibiotic exposure, which senior clinicians with seven or more years of experience prioritized based on accumulated personal experience over external guidelines. At the same time, institutional culture including routine prescribing practices or preferences of specific departments also played a substantial role.

Table 3. Supporting themes related to prescribing empirical antibiotic in the emergency department.

Theme	Subtheme	Subcategory
Challenges in prescribing antibiotics in the ED	Diagnostic uncertainty	Difficulty in diagnosing infection based on clinical symptoms (n=5) and initial test results (n=3); Limited diagnostic tests available in the ED (n=1)
	Knowledge gaps	Limited knowledge on antibiotic selection in various clinical scenarios (n=6); Lack of structured education/training on antibiotics (n=1)
	Practical prescribing difficulties	Situation-specific dosing (especially renal function) (n=2); Mixed fluid selection (n=4); Infusion rate determination (n=3); Difficulty in identifying available antibiotics in the institution (n=2)
	Limited access to expert support	Limited access to infectious disease specialist consultation (n=1)
Factors influencing antibiotic decision-making	Patient-related factors	Severity of illness (n=10); patients’ comorbidities (n=5); Prior antibiotic prescription (n=4)
	Institutional culture	Department- or physician-specific antibiotic preference (n=5)
	Expert consultation	Advice from infectious disease specialists (n=3)

Numbers in parentheses indicate the number of participants.

ED, emergency department.

2. Barriers to the use of existing antibiotic guidelines

Not all ED clinicians were aware of existing antibiotic guidelines, and even among those who were, the guidelines were rarely used in routine practice. This underutilization was consistently attributed to poor usability and limited applicability to real-world ED settings (Table 3). Participants noted that current guidelines are text-heavy and difficult to consult in environments where multiple patients require simultaneous evaluation and prompt decisions, making them less accessible than using search-based web resources. While senior clinicians highlighted structural discrepancies between international textbook guidelines and local resistance patterns, junior clinicians heavily relied on digital reference apps like UpToDate but lacked baseline awareness of domestic guidelines due to limited institutional promotion.

Moreover, participants were often confused by a discrepancy between guideline recommendations and actual ED practice. Existing guidelines are typically organized by single infection foci, which limits their applicability in situations where multiple co-infections are suspected and prioritization of treatment targets is uncertain. This operational barrier was predominantly emphasized by emergency medicine clinicians, whose antibiotic choices were heavily dictated by pre-configured order sets and the specific preferences of receiving departments to facilitate patient handovers. As one participant noted, “When a single infection is suspected, the guidelines can be helpful, but when two or more co-infections are suspected simultaneously, it becomes difficult to decide on antibiotics based on the guidelines alone.” (Table 4). In addition, antibiotic selection in the ED was often influenced by institutional norms or the preferences of anticipated admitting departments. One participant stated that, “In our hospital, the routine antibiotic prescribing practices do not always align well with the guidelines. Since antibiotics are often changed after admission by the receiving department, it becomes difficult to strictly follow the guidelines in the ED” (Table 4).

Table 4. Clinicians’ perceptions of existing antibiotic guidelines and requirements for ED-specific antibiotic guidance.

Main theme	Subtheme	What participants emphasized	Representative quotes
Problems with existing antibiotic guidelines in the ED	Poor usability of existing guidelines	Existing antibiotic guidelines were perceived as difficult to use in the ED due to low readability (n=5); unclear prioritization of antibiotics (n=1); fragmented or hard-to-access resources (n=2); and uncertainty regarding whether recommendations were up to date (n=1).	Compared to web-based resources such as UpToDate, the guidelines are less accessible, so we tend not to look them up. Furthermore, they are mostly text-heavy, which makes them difficult to apply quickly in the emergency department.
	Limited applicability to the ED context	Participants perceived a mismatch between existing antibiotic guidelines and real-world ED practice. Clinicians noted that guideline recommendations often did not align with institutional practices or the transitional nature of care in the ED, where antibiotic selection is influenced by preference of anticipated admitting departments (n=5). In addition, guidelines were perceived as insufficiently addressing complex clinical scenarios (n=6); such as suspected co-infections or an unclear infection focus (n=1); which limited their applicability in actual ED settings.	When a single infection is suspected, the guidelines can be helpful, but when two or more co-infections are suspected simultaneously, it becomes difficult to decide on antibiotics based on the guidelines alone.
User-defined requirements for usable ED antibiotic guidelines	Algorithm-based and concise guidance	Clinicians emphasized the need for concise, algorithm-based guidance that supports rapid decision-making by integrating patients’ overall clinical condition including age, risk factors for antimicrobial resistance, and clear contraindications (n=6).	Because of time constraints in the emergency department, participants emphasized the need for a simple, standardized tool rather than lengthy documents, ideally limited to one or two pages to facilitate real-time use.
	Practical prescribing information	Participants highlighted the importance of practical, situation-specific prescribing information, including clear dosing recommendations (n=2); administration details (mixed fluid and infusion rate) (n=1); and information on antibiotics available within the institution (n=1).	If information such as dosing, renal dose adjustment, and administration details were displayed together when selecting an antibiotic, it would be much more helpful for actual prescribing.
	Integration into clinical workflow	Participants stressed that antibiotic guidelines should be embedded into the clinical workflow, rather than requiring active searching, through highly accessible formats such as point-of-care summaries (n=2); integration into electronic prescribing systems (n=1); and supplementary multimedia resources (n=1).	A one-slide summary, such as a single PowerPoint slide placed next to the prescribing computer, would be most practical for use during actual prescribing in the ED.
			Participants suggested that integrating guideline recommendations into the electronic prescribing system, such as through pop-up prompts, would substantially improve usability.
	Ongoing support and reinforcement	Ongoing audit and feedback on antibiotic prescribing practices were considered important for reinforcing guideline use and promoting appropriate empiric antibiotic selection in the ED (n=7).	In the ED, follow-up after initiating empirical antibiotics is limited once patients are admitted, which reduces attention to subsequent outcomes. Receiving regular feedback on inappropriate or changed antibiotic prescriptions would make it easier to improve future prescribing decisions.

Numbers in parentheses indicate the number of participants.

ED, emergency department.

3. User-defined requirements for ED-specific antibiotic guidelines

Based on the clinical challenges and operational barriers identified in Table 3, participants outlined specific, user-defined requirements for developing effective, ED-specific antibiotic guidelines. These comprehensive qualitative findings and core requirement themes are structured and summarized in Table 4. Given these characteristics of the ED practice, participants emphasized the need for user-friendly guidelines tailored to time-limited clinical settings (Table 4). First, clinicians highlighted the importance of concise, algorithm-based formats that allow quick orientation at the point of care, preferably in a standardized summaries limited to one or two pages and structured by key factors such as age, comorbidities and risk factors for resistant pathogens (Table 4). Second, participants stressed that practical prescribing details – such as renal dose adjustments and administration rates – should be integrated directly into the guidelines. As one participant noted, “It would be helpful to have a guideline that allows us to see, at a glance, which antibiotics can be used safely in the initial ED presentations, with concise information on dose adjustments for renal dysfunction.” (Table 4). Third, participants emphasized that guidelines should be embedded into the clinical workflow rather than requiring active searching, suggesting highly visible point-of-care materials (e.g., one-slide summaries placed near prescribing computers) and integration into electronic medical recording (EMR) systems through popup prompts or decision-support tools (Table 4). Finally, participants commonly mentioned that ongoing update of guidelines and frequent feedback on prescribing outcomes would be important for reinforcing guideline use and promoting appropriate empirical antibiotic prescription in the ED (Table 4).

Discussion

This qualitative study explored ED clinicians’ experience with empirical antibiotic prescribing and identified factors limiting the use of existing antibiotic guidelines, as well as user-defined requirements for ED-specific guidance. Our findings suggest that the limited use of current guidelines in the ED reflects not only a baseline lack of awareness among a subset of frontline clinicians, but also a fundamental misalignment between guideline format and the realities of emergency care, underscoring the need for context-sensitive approaches to antibiotic decision support in the ED. To bridge this gap in awareness, hospitals should implement active dissemination strategies rather than relying on passive document storage. Integrating automatic notifications into the EMR system or distributing targeted institutional email alerts could significantly enhance baseline guideline recognition among frontline clinicians, particularly rotating junior residents.

Furthermore, even among clinicians who are aware of the guidelines, comprehensiveness itself emerged as a barrier in time-pressured ED settings. They are typically developed as detailed reference documents, organized by specific infection types and clinical scenarios. For example, current guidelines for urinary tract infections provide extensive recommendations covering a wide range of disease entities and management strategies [11]. However, this level of details may limit their practical use in time-pressured ED settings. In situations requiring prompt decision-making under diagnostic uncertainty, ED clinicians reported having little opportunity to consult lengthy documents or engage in guideline-based learning during clinical care. This highlights a structural mismatch between the design of existing guidelines and ED practice, where immediacy and cognitive simplicity are essential.

Also, our findings indicate that the lack of site-specific customization further limits the practical utility of existing guidelines. Although guidelines are designed for broad applicability across diverse healthcare settings, they are inherently intended to serve as adaptable frameworks. However, in practice, the absence of guidance tailored to local institutional contexts–such as differences in clinical workflows, resource availability, and prescribing culture–often leads routine practices to outweigh general recommendations. Consequently, existing guidelines frequently fail to function as practical decision-support tools within ED or institutional specific contexts. Previous studies have similarly emphasized the importance of adapting clinical practice guidelines to local settings, suggesting that contextualization can improve both usability and implementation. Structured approaches to guideline adaptation have also been proposed in prior literature, supporting the feasibility of tailoring process [12]. Taken together, our findings reinforce the need for locally adapted, ED-specific guidance that better reflects real-world clinical decision-making conditions. Furthermore, while general web resources like UpToDate offer comprehensive global evidence, they lack local context. Developing locally adapted digital guideline platforms that integrate institutional antimicrobial resistance patterns and specific formulary recommendations can bridge this gap. Such digital platforms provide frontline clinicians with immediate, locally actionable data that general reference tools cannot replicate.

Building on these findings, our results point to key principles for the development of ED-specific antibiotic guidelines. Clinicians emphasized the importance of concise, algorithm-based formats that support rapid initial decision-making under uncertainty. While existing guidelines are commonly organized by infection sites, such formats may be poorly aligned with ED workflows, where multiple potential diagnoses must be considered simultaneously. Importantly, ED-specific guidance should be designed to balance simplicity with safeguards against overgeneralization by clearly highlighting situations that warrant broader clinical consideration or escalation. Integrating practical prescribing information directly into guideline formats was also viewed as essential for real-world usability. To maximize real-world usability, ED-specific guidelines can leverage EMR optimization. Automated features within the computer provider order entry system—such as automatic renal dose adjustments based on real-time serum creatinine, automated infusion rate calculators, and immediate visibility of institutional formulary stocks—can dramatically alleviate cognitive load under time pressure. Notably, some existing context-adapted guidelines have attempted to present simplified, algorithm-based approaches while incorporating clinically relevant considerations, providing useful references for the development of ED-specific guidance. Although these guidelines were also organized by infection sites, they demonstrate that such approaches can be feasibly adapted to support decision-making in time-sensitive clinical environments [13].

In addition, ongoing education and feedback on prescribing outcomes may further facilitate the uptake and refinement of ED-specific guidelines. Given that follow-up after initiating empirical antibiotics is often limited once patients are admitted, structured feedback may provide valuable opportunities for clinicians to reflect on and improve their prescribing practices, thereby facilitating the uptake of guideline-based decision-making. Feedback-based approaches, particularly audit-and-feedback strategies, have been recognized as effective methods for improving clinician prescribing behavior [14], and previous studies have also demonstrated that multifaceted interventions incorporating both education and feedback can enhance guideline-concordant antibiotic use [15,16]. Therefore, the development of ED-specific guidelines, when combined with ongoing education and feedback, may facilitate the sustainable integration of guideline-based prescribing into routine clinical practice.

It is important to note that while data collection occurred in 2022, the ASP landscape in Korea underwent a major transformation in November 2024 with the nationwide expansion of national ASP policy initiatives and financial incentive programs [17]. This policy shift has mandated hospitals to intensify their ASP efforts. Consequently, the barriers and user requirements identified in our study—such as the need for seamless clinical workflow integration and rapid decision support—have become even more critical. The current policy environment provides a powerful institutional catalyst for implementing the user-centered digital guideline platforms proposed in this study.

This study has some limitations. First, the FGIs were conducted in a relatively small sample across tertiary hospitals, which may limit generalizability to other clinical settings. Second, we did not formally or prospectively monitor data saturation using specific qualitative verification frameworks during the interview process [18,19]. Consequently, we cannot rule out the possibility that additional, subtle subthemes might have emerged had we expanded the sample size or included a broader range of institutions. Nevertheless, according to the methodological framework by Malterud et al., sample adequacy can be evaluated through the concept of "information power," which suggests that a study requires a smaller sample size when the participants possess high specificity and expertise relevant to a narrow research aim [18]. Given that our participants were frontline clinical experts directly responsible for empiric antibiotic decision-making under identical ED constraints, the collected data provided sufficient depth and information power to address our core research questions. In addition, as a qualitative study, our findings reflect clinicians’ perceptions rather than measured prescribing outcomes. Despite these limitations, our findings provide meaningful insights into real-world challenges of empirical antibiotic prescribing in the emergency department by directly incorporating end-users’ needs.

In conclusion, this study highlights the need for ED-specific guidelines and suggests strategic directions for their refinement in real-world healthcare environments, particularly in ED. By centering clinicians’ perspectives, future work should focus on the development of department-specific antibiotic guidelines that are both usable and flexible, followed by evaluation of their impact on prescribing practices and patient outcomes. Ultimately, improving the usability and applicability of antibiotic guidance in the actual clinical field may contribute to antibiotic stewardship efforts in real-world practice.