Table 4.
Quotes From Participant Interviews and Observations, Shown By Theme
| Theme | Participant | Quote | |
|---|---|---|---|
| 1. Accessibility of information | Registrar, postimplementation | 1.1 | Due to limited knowledge of antibiotics, I would just give a broad-spectrum antibiotic, because to me that makes me well covered. The patient is going to improve … so whatever this patient has he is going to improve. But now at least I am able to sit down and think, what does, what do the guidelines say. |
| Registrar, postimplementation | 1.2 | For UTI, we used to using (sic) ciprofloxacin and now they are saying use nitrofurantoin and I keep forgetting the dosing because I’ve never used it my whole life, this is the first time. Yeah, so they do (help). | |
| Intern, preimplementation | 1.3 | I remember the time we were switching from cefotaxime to ceftriaxone nobody knew what doses—you may find a meningitis patient given cefotaxime 1g bd, another meningitis patient getting 1g cefotaxime TDS, another bacterial meningitis got 1g od for about 3 days—which is when I saw the patient and changed the dose to the dosage I thought was nice. I feel we sometimes lack the guidance. | |
| Consultant, preimplementation | 1.4 | There is so-called “Malawi standard treatment guidelines.” There are some antibiotic guidelines but no proper antibiotic guidelines in Queens that we can use as a facility as such. We do have a medical handbook in our department that we use, and it does help us, it does guide us on what antibiotics we should give, but it’s not very detailed. I feel, it’s not very specific, it’s general, at the end of the day it’s up to the clinician, should I give this antibiotic or not, I feel, because of a lack of a proper guideline, at times patients are started on the strongest antibiotic we have available, that’s ceftriaxone, I find maybe they don’t even meet the criteria to have that antibiotic, but everyone’s on ceftriaxone. I think we don’t have proper guidelines, in short. | |
| Consultant, postimplementation | 1.5 | I think the fact that they’ve been made available in electronic forms and also there’s a small booklet which you can carry to the wards. I think that it’s a step in the right direction, I think we should have less excuses for not following the guidelines. | |
| 2. Trust in the content | Consultant, postimplementation | 2.1 | I think we were part of the discussions and we were all consulted and told to make suggestions of the guidelines. |
| Consultant, postimplementation | 2.2 | So I mean essentially the guidelines are based on the data that has been generated over the years in terms of the likely, the commonest organisms that are affecting patients in our setting and …we were all consulted and told to make suggestions. | |
| Consultant, postimplementation | 2.3 | They are realistic guidelines … and what they’ve done, is they’ve made sure that most of the drugs that are usually in stock are there, so they are not some fancy drugs that you can hardly find here. | |
| Registrar, postimplementation | 2.4 | In terms of coverage, it covers most of the important infections we see in our setting. And in terms of management I think it also gives us alternative in case 1 drug is out of stock there are always alternatives. | |
| 3. Awareness and promotion | Consultant, postimplementation | 3.1 | I think the only notable change that I can comment is on the usage of ceftriaxone, because normally we get a report is it on every Thursday before the ward round on the percentage of ceftriaxone usage in the department, so I think from the figures, from the initial figures and the current figures it seems there has been a significant drop in terms of … usage of ceftriaxone. I think now not many people they are using ceftriaxone so meaning now they are following the guidelines so not giving ceftriaxone to each and every patient. |
| Registrar, postimplementation | 3.2 | Yeah, so, since I think as a department there was quite a lot of awareness and raising awareness that we would have the antibiotic guidelines. | |
| 4. Operational barriers | Registrar, postimplementation | 4.1 | Let’s say there’s amoxicillin, but I’d want to give something slightly more broad spectrum, like augmentin. But there isn’t. And probably the next best thing is ceftriaxone. So sometimes you use an antibiotic which you didn’t necessarily want to use. |
| Registrar, preimplementation | 4.2 | One of them is because the oral drug is out of stock, so the only choice I had was to give a broad spectrum that was IV, but if I had a chance I would have given an oral antibiotic. It has happened so many times, not once. | |
| Registrar, postimplementation | 4.3 | For example there should be commitment from management to ensure that even simpler antibiotics should be made readily available because even if broad-spectrum antibiotics only are available and patient has come in with simple, community-acquired pneumonia, people may be tempted to use broad-spectrum antibiotic, because they are only what is available. So, I think there should be a commitment from the management team to ensure that more antibiotics are available. | |
| Observation, postimplementation | 4.4 | All the (noninfective) neurological cases viewed this morning had an infective differential. All of these patients had HIV so this is not just speculation, it’s a real risk. Insufficiency of neuroimaging means that the infective cause cannot be ruled out until we get an MRI or the LP or blood culture results get back—all of which will be 5 days. | |
| Consultant, postimplementation | 4.5 | When I arrived in 2009, the numbers of patients on our wards was really horrendous … so there will be 1 on the bed, 1 on the floor, all the way into the corridors. So if you had 2 trained nurses per shift it meant that they would be sitting at their desk drawing the antibiotics the whole day. … if they were to do that 4 times a day they did nothing else. So … patients stared getting maybe 1 dose, or 2 doses … but never 4 doses. So we sort of like just slowly drifted towards … once daily antibiotics, ceftriaxone. | |
| 5. Hierarchical relationships and prescribing practice | Observation, postimplementation | 5.1 | There is a palpable power dynamic on this ward round. … Consultant says out loud we should stop ceftriaxone and wrote “CSF normal, stop ceftriaxone.” He did not look at the drug chart and did not cross ceftriaxone off. No-one else on ward round crossed off … and we moved on to the next patient. Certainly, ward round participants don’t seem keen to speak unless directly addressed, maybe they don’t want to cause disruption to the ward round by stopping to cross off antibiotic. |
| Medical student, preimplementation | 5.2 | But as students when you see the files and you see people prescribe amoxicillin, ceftriaxone, you think that’s the way to go because we see people practicing it, but then sometimes when you’re on ward round you see a consultant prescribing an antibiotic which you never know is here. | |
| Registrar, preimplementation | 5.3 | I think the interns who come to the department, they see most of the time people are on ceftriaxone, so when they are stuck, they will think that maybe by giving that, they will be off the hook. | |
| 6. Rationalized overprescribing | Registrar, preimplementation | 6.1 | That could be 1 possibility, because if I am certain you can just give an antibiotic which you feel is safe. |
| Consultant, postintervention | 6.2 | And when the patients are perceived to be quite unwell, that’s where the problem of sticking to the guidelines seems to be an issue. | |
| Consultant, postintervention | 6.3 | It basically makes people not to think because they have a knee-jerk reaction to everyone who has a fever, to give them ceftriaxone without thinking as to where the focus of infection is, so that you can choose an appropriate antibiotic for the focus of infection. So everyone just gives ceftriaxone as a fall-back position. So it stops people thinking about what is their ideal treatment in this setting. |
Abbreviations: bd, twice daily; CSF, cerebrospinal fluid; HIV, human immunodeficiency virus; IV, intravenous; LP, lumbar puncture; MRI, magnetic resonance imaging; od, once daily; tds, three times daily; UTI, urinary tract infection.