Guideline relevance, diagnostic uncertainty, fear and hierarchy: Intersecting barriers to antibiotic optimization in respiratory infections.

Prescribing of antimicrobial agents for respiratory infections is one of the highest volume area of hospital antibiotic prescribing, accounting for circa 16% of hospital antimicrobial prescriptions in Australia and international studies. 1 In a global environment of escalating antimicrobial resistance, limited new antibiotic development and a desire to reduce antimicrobial misuse, there is an increasing imperative to optimize across all settings to preserve options for the future. Yet, despite increasing regulatory requirements, antibiotic restrictions and enhanced surveillance measures, management of respiratory infections in hospitals commonly involves inappropriately long durations of antimicrobial therapy and broader spectrum treatment than is required. The reasons for this are complex and have been relatively opaque, but an emerging body of evidence supports the significant influence of social factors on antimicrobial prescribing in respiratory infections, which may potentially be difficult to shift with the traditional ‘diffusion 'model of knowledge dissemination (i.e. strategies focusing on surveillance, education and regulatory approaches to antimicrobial optimisation).This model of optimization—dominating current approaches in many hospital contexts—may not account for key contextual factors which can act as significant barriers to practice change, such as perceptions of risk and hierarchical relationships within hospitals. [ABSTRACT FROM AUTHOR]