Themes identified from SEIPS components with corresponding representative quotations
| Theme | Representative quote |
| Organisation | |
| Antimicrobial stewardship programme | 1. “We audit to make sure the right indication is happening. We check to see the dosage is correct and monitor what’s happening here to track our prescriptions.” (Pharmacist) |
| 2. “Every year we do something with the antibiotic prescription program. Along with infection control. Usually a 3 day program for doctors and 1 day is dedicated to antibiotic stewardship. Speakers from all over the country [come] and we take about 30–35 doctors a year and try to teach them about antibiotic stewardship.” (Infection control nurse) | |
| 3. “The medical superintendent is a part of our team. I don’t think you can get much higher up than that. The management is very supportive.” (Pharmacist) | |
| Microbiology laboratory | 4. “Our microbiology lab is one of the best in the country. They are very reliable and help us immensely.” (Physician) |
| 5. “Whenever the lab grows something in the culture, could be 6 hours, ten hours, we are called and told. So that does impact our management. If we are thinking about a gram positive illness and we get a culture that’s gram negative, which is grown very quickly, we totally change our report. We are informed pretty quickly.” (Physician) | |
| Clinical pharmacist availability | 6. “[Pharmacists are] not routinely in the ICU. I wish more pharmacists would tell physicians their doses or their drug interactions are wrong, but I don’t see them in the cardiac or pediatric ICU.” (Physician) |
| 7. “We have one pharmacist in our ICU, she visits. The problem with her is she’s overworked. She’s alone. She comes on the rounds only sometimes and comes around and checks the antibiotics dosing is correct. But duration and all others are decided by physicians. If there were more of them it would be much better.” (Physician) | |
| 8. “If a clinician is working alone, we may not have much concern about things that pharmacists are more aware of, like drug interactions. Routine medications may have interactions also, so pharmacists’ help is needed. That type of information is more with the pharmacists, not the clinicians. They are not always available.” (Physician) | |
| Person | |
| Antibiotic stewardship knowledge | 9. “Antibiotic stewardship is a standardized practice with the right treatment at the right time.” (Physician) |
| 10. “To me antibiotic stewardship is to start judicious antibiotics…I won’t say to start low antibiotics, I say to start optimum antibiotics.” (Physician) | |
| 11. “Most of us here are aware of these ideas. For us, it’s about everything that has to do with a prescription. The ultimate aim is judicious use of antibiotics. We need to use the right antibiotics, the right dose.” (Physician) | |
| Physician resistance to antibiotic stewardship policies | 12. “I think clinicians are empowered to think that they know best. They need to recognize the roles of the microbiologists and the pharmacists and should not feel low that they have asked for help.” (Physician) |
| 13. “Challenges come from navigating human behavior. Sometimes you’ll recommend things but people just won’t listen to you.” (Infection control nurse) | |
| Tasks | |
| Antibiotic prescribing | 14. “We have a high patient load and socioeconomic status is a big deal. Poverty and malnourished children are a reality. We can’t wait for cultures. We have protocols to start them on antibiotics according to which ones have been most successful here.” (Physician) |
| 15. “I think it’s a problem all over India, because the first antibiotics they prescribe is the carbapenems. And once they prescribe it is never de-escalated or rarely de-escalated. Basically they go, ‘let’s continue. What the culture says? I don’t want to do that. Let’s just continue because he’s improving.’ So it’s a major, major, major problem.” (Physician) | |
| Workload | 16. “Sometimes we are busy and we forget pre admission drugs which are missed because we are more worried about the current problems, and there are so many the patient is already on, that we need to continue.” (Physician) |
| 17. “Our work here does affect how long you can spend on individual cases.” (Infection control nurse) | |
| Tools and technology | |
| Antibiogram | 18. “It is an annual antibiogram. We divide it into gram positive, gram negative, and yeast. We also have a blood gram positive from blood isolates, negative, and yeast. They are separate. We follow international guidelines so for any isolate that is more than 30, we take them and follow the rules. Every year it is updated. This year they are trying to involve more pharmacists.” (Infection control nurse) |
| Electronic medical record | 19. “If I look today at the record, I can only see what they took today. The current medications only. Not what they got yesterday. I can’t trace the meropenem. To see all the drugs we have to go to the paper medical record room. It’s a very tedious process. We don’t know the dose or duration or all the drugs…if the patient returns in a few weeks, we don’t know what they were taking and what will be effective.” (Pharmacist) |
| 20. “I see 80 patients a day. So it’s not possible for me to spend so much time logging in, recording all this. I don’t think it’s possible unless I had someone sitting next to me doing just that.” (Physician) | |
| Environment | |
| Posters or signs promoting antibiotic stewardship awareness | 21. “It’s only in protocols, which we do print out only for doctors. Nurses don’t see that.” (Physician) |
| 22. “We have some print-outs on our notice board about colistin and other higher-end antibiotics…but we don’t have posters. As for the printouts, they aren’t that catchy.” (Physician) | |
| High levels of community antibiotic use | 23. “Outside the hospital this is a rampant problem in India. There is much abuse and misuse of antibiotics. Anyone can just go to a roadside pharmacy and describe their symptoms and get antibiotics over the counter just like that. They just go to the guy sitting there and get whatever. I think we should make it much harder to get antibiotics.” (Physician) |
ICU, intensive care unit; SEIPS, Systems Engineering Initiative for Patient Safety.