Five main themes emerged regarding the factors that influence decisions to prescribe ceftriaxone for patients with CAP:
Clinical intuition vs. structured evaluation of severity Clinical uncertainty
Prior experience Source of guidance Prescribing etiquette.
100
Clinical intuition vs. structural evaluation of severity
All participants mentioned that they would use ceftriaxone in cases of severe CAP. However, participants mentioned different methods to identify patients with severe CAP. Although most interviewees were aware that using a severity assessment tool is recommended, only some of the participants actually used such a tool, and fewer used one of the severity tools specifically recommended by TG14, i.e. SMART-COP or CORB.
“It is quite easy really, in the absence of guiding from microbiology, it’s a risk
stratification based on the severity score. I would use the Therapeutic Guidelines, really. For empirical clinical management, [I would prescribe antibiotic regimen] based on the severity scores such as the CORB and SMARTCOP (P5 G)”.
Some of the doctors who used a severity assessment tool, used an alternative such as PSI or CURB65, either due to familiarity and/or because that was what they had been taught to use.
“The one that springs to mind is CURB65 because it’s the one I know. Other ones I can’t remember. That [CURB65] is just the one I’ve learned (P2 G).”
The other participants mentioned that they relied solely on their clinical judgment to assess the severity of CAP.
“Most of it is the clinical picture of the patient. You see patients have difficulty breathing, short of breath, can’t really speak, … are not stable, lower blood pressure, respiratory rate is elevated… .all of these things make you say OK this patient is not fine (P3 R).”
Several reasons were stated regarding why CAP severity scores are not routinely used. The reasons included experience, education, and the changes in the recommended scoring system.
“I am aware of a quite a number of scores and systems one could use... But I guess that as one goes through your career, sometimes just through your own judgment and knowing about few key things can kind of get a sense of that yourself (P4 C).”
101
“I know there are [severity tools], but they didn’t teach us at med [medical] school. Like there is this SMART-COP and things like that. But in ED I haven’t necessarily been encouraged to use that on the front line. I just go by your kind of gut feeling (P8 G).” “In the past, they use PSI score, but this now has disappeared. I can’t find it in TG anymore. So I just generally go by the clinical picture (P7 G).”
Some participants mentioned that in those cases of CAP likely to be admitted as an in- patient, the severity warrants ceftriaxone-based therapy.
“for empirical, it is normally ceftriaxone or some other 3rd generation cephalosporin 1 gram or 2 grams IV daily plus macrolide (azithromycin)… that’s normally for patients who are for admission (P3 R).”
It was frequently mentioned that the perception of severity is often influenced by the presence of co-existing diseases, as one interviewee said:
“A lot of patients have pneumonia which is only severe because of the comorbidity…the number of diabetic, ischemic heart disease, heart failure, …much more complicated patients than perhaps they were 20 years ago (P1 C).”
Clinical Uncertainty
Clinical uncertainty was a common theme that all participants believed could be a major factor explaining prescription of ceftriaxone outside of guideline recommendations. An example of this was where the prescriber was unable to identify the source of infection or a suspicion that there may be multiple sources of infection.
“It is not clear in the first day what is really going on with this patient… it is not that clear it is the pneumonia causing the patient’s presentation. For the inpatient team, it is different story, but for ED you don’t really know what the patient has, you are the first line of the treatment (P7 G).”
“If I was not entirely sure about the source, if there is concomitant UTI, I think ceftriaxone gives good broad spectrum coverage (P6 R).”
Some participants mentioned that the time limitations in the ED could be one reason to prescribe ceftriaxone even if they are not sure about the diagnosis.
102
“I think in the emergency setting sometimes because people really in a hurry, they can’t really decide what to do, and they want to push the patients as soon as possible and let the patient go out from the ED and decide if the patient should go home or should be admitted. Actually, that’s the nature of the ED, to decide as quickly as you can. Sometimes, I feel that’s the reason why we prescribe ceftriaxone in ED (P3 R).”
Prior experience
It was frequently mentioned that the broad spectrum and generally good safety profile of ceftriaxone might make it attractive to be used in the ED as one interviewee put it:
“I guess because ceftriaxone is a fire and forget weapon. Give it then the patient gets better. ..and there are very rare major side effects acutely. I guess people think that they cover their back by giving ceftriaxone (P7 G).”
Some participants stated that ceftriaxone leads to less treatment failure than may be seen with other agents recommended for non-severe CAP. Talking about this issue, an interviewee said:
“Just from my experience it [ceftriaxone] always works. I haven’t seen a lot of treatment failure with ceftriaxone. On the other hand, benzylpenicillin, I’ve seen several patients not getting better with that (P7 G).”
Source of guidance
Participants used different resources to guide their choice of antibiotic therapy, including ceftriaxone, for patients with CAP.
All participants stated that they utilised Therapeutic Guidelines (TG) to inform empiric treatment of CAP patients in the ED.
“I normally follow the TG [Therapeutic Guidelines: Antibiotics]. You need to make the decision whether to admit the patient or send the patient home. I found this quite helpful (P7 G).”
However, when asked about their thoughts regarding empirical management of CAP, some participants reported occasional use of antibiotic regimens that were not in accordance with TG.
103
“I feel that I would rather give people [IV] amoxycillin rather than straightforward benzylpenicillin because I think it is slightly broader…I have never prescribed ceftriaxone for most people with pneumonia…sometimes I think I tend to give old smokers oral
Augmentin [amoxycillin/clavulanic acid] when probably it is inappropriate, but they’ve been on it before and it’s got extended cover and it probably has less resistance (P1 C).”
Some participants also utilised international references to seek guidance regarding treatment decisions.
“In the hospital I usually use UPTODATE, which is an American site. We normally have it in the computers at the hospital. ..I know there are some other sites and applications would help you as well. I really feel comfortable with UPTODATE (P3 R).”
Prescribing etiquette
Discussion with colleagues regarding the use of ceftriaxone for CAP ranged from extremely rare with consultant participants, extremely rare to sometimes with registrars, to most of the time and always with residents.
“No, not for ceftriaxone…the only time that I ask for sort of guidance are for people with sensitivities to antibiotics or when it is an unusual infection, significantly
immunocompromised patient, then I might talk to ID about what would they like to give…invariably, it is not ceftriaxone (P1 C).”
“I sometimes consult my colleagues, but I feel comfortable if I feel the patient is sick enough; I just give it. Sometimes I consult with my consultant whether they are happy with that plan. But in general if it is a sick patient, I don’t have too much doubt in giving them unless they are allergic and need to solve other problem (P7 G).”
“Definitely I use the consultants because I’m a junior doctor... Because I was a junior I used to discuss it [ceftriaxone]; for example, before I give it to the patient (P3 R).”
All consultants and most registrars thought that the inappropriate prescribing of ceftriaxone might originate with junior doctors.
“It is difficult… particularly if people [juniors] have been working in these areas with septic patients in intensive care and oncology, and they have a rotation to ED, then they are going to feel that’s appropriate to use those antibiotics for the sicker patients, where the sickness is not necessarily related to the… you know the correlate between antibiotics and unwellness (P1 C).”
104 It was also mentioned that there is less restriction on prescribing ceftriaxone in the ED
and most of the time senior doctors do not object when they have been asked. Participants also reported that the general principle of ‘do no harm’ applies to the use of ceftriaxone due to its safety.
“I really sometimes think that we just give ceftriaxone to patients unnecessarily. And actually we did give those patients ceftriaxone unnecessarily many times. I think you can see it with all doctors as a resident, as a consultant, as everyone. ..I always think that there is feeling in all of doctors that antibiotics won’t do anything [harmful] “one or two doses of ceftriaxone won’t kill anyone (P3 R).”
105
4.4.
Discussion
Following the work described in the previous chapter to identify barriers that hinder doctors from adhering to recommendations, this qualitative study was designed to determine factors that influence ED doctors to prescribe ceftriaxone outside the TG14 recommendations. Five broad themes emerged from the analysis that could describe and explain some of our findings from the baseline audit (Chapter 2) and survey study (Chapter 3).