Context-sensitive antibiotic optimization: a qualitative interviews study of a remote Australian hospital setting

Antibiotic optimization is an urgent international issue. Regulatory frameworks, including the requirement to have a functioning antimicrobial stewardship (AMS) programme, are now ubiquitous across the hospital sector nationally and internationally. However, healthcare is ultimately delivered in a diverse range of institutional settings and social contexts. There is emerging evidence that implementation of antibiotic optimization strategies may be inappropriate or even counterproductive to attempts to optimize in atypical healthcare settings.To document the experiences and perspectives of clinical staff in a remote healthcare setting in Australia with respect to antimicrobial use, and strategies for optimization in that environment.Semi-structured qualitative interviews were conducted with 30 healthcare professionals, including doctors, nurses and pharmacists, from a remote hospital in Queensland, Australia.Four themes were identified from the analysis as key challenges to antibiotic optimization: (i) AMS as externally driven, and local knowledge sidelined; (ii) perceptions of heightened local population risks, treatment failure and the subsequent pressure to over-use of antimicrobials; (iii) interprofessional relationship dynamics including medical hierarchical structures perceived as a barrier to AMS; (iv) a clinical workforce dominated by transient locum staff and other process issues were perceived as significant barriers.The perceptions of healthcare professionals in this site lead to the conclusion that antimicrobial regulations and practice improvement strategies more generally are unlikely to succeed if they fail to accommodate and respect the context of care, the resource and structural constraints of the setting, and the specificities of particular populations (and subsequent clinical 'know-how')