Identifying barriers to the rapid administration of appropriate antibiotics in community-acquired pneumonia

Background: Despite multiple guidelines for management of community-acquired pneumonia (CAP), barriers to guideline use are rarely evaluated.

Methods: We performed quantitative and qualitative surveys of junior doctors before implementation of a CAP management pathway. After implementation, we identified patient-related determinants of pathway adherence by multivariate analysis.

Results: We surveyed 83 (77%) of the 108 junior doctors working in acute medicine between August 2001 and July 2002 and selected 8 for in-depth interview. We identified five main themes that influence pathway adherence. First, education (recognized to be insufficient on antimicrobial therapy) and experience: increasing clinical experience was associated with greater knowledge of pathway content, but decreasing likelihood of consulting the pathway. Second, attitudes to CAP: doctors recognized that they had not treated CAP with respect early on. Third, work intensity and lack of senior support were barriers to good practice. Fourth, guideline factors: they need to be simple enough to be easy to use while containing enough information to be useful. Fifth, CAP is sometimes difficult to diagnose on admission. Notably, when given three clinical scenarios only six (7%) of respondents assessed CAP severity correctly. In the intervention study, early administration of antibiotics was associated (P<0.05) with indicators of increased severity of illness (pulse, respiratory rate, oxygenation and temperature) in addition to being admitted to the intervention hospital (P<0.001).

Conclusions: Some of the identified barriers could be overcome by undergraduate and postgraduate education. Howev er, equally important are organizational barriers that can only be overcome by systems redesign.