Research Article| Volume 101, ISSUE 4, P461-466, April 2019

Download started.


Critical points in the pathway of antibiotic prescribing in a children's hospital: the Antibiotic Mapping of Prescribing (ABMAP) study



      The World Health Organization has identified antimicrobial resistance (AMR) as one of the most significant global risks facing modern medicine. Interventions to improve antibiotic prescribing have so far had limited impact.


      To understand the barriers to effective antibiotic prescribing.


      Mixed methodologies were used to investigate prescribing behaviours to identify the critical points in the antibiotic prescribing pathway for hospital inpatients. We assessed knowledge, experience or empowerment of prescribers, organizational factors, and use of the laboratory. Phase 1 was an online survey to map barriers and facilitators to antibiotic prescribing (56 participants). Phase 2 consisted of focus groups and interviews to gain more understanding of prescribing behaviours (10 participants). Phase 3 was an online survey to obtain opinions on possible solutions (22 participants).


      Barriers to prescribing were: laboratory factors 71.6%, resource issues 40%, time constraints 17.5%, pressure from others 52%. Ninety-three percent of prescribers were concerned about AMR. In three scenarios only 9% were confident not to prescribe antibiotics for a patient without bacterial infection; 53% would prescribe unnecessarily broad-spectrum antibiotics for pneumonia. Only 5% would de-escalate antibiotics in a microbiologically confirmed bacteraemia. Despite concerns about AMR, prescribers did not perceive that continuing antibiotics for individual patients might promote resistance. Prescribers were unwilling to change antibiotics out of hours and reported that they preferred professional support for antibiotic prescribing.


      There was a marked disparity between prescribers, self-reporting of prescribing behaviour and responses to clinical scenarios. It was not clear whether training alone would change behaviours. Prescribers desired a directive mechanism to support antibiotic prescribing and stewardship.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hospital Infection
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • World Health Organization
        Global action plan on antimicrobial resistance.
        WHO Press, Geneva2015
        • Public Health England
        Start smart – then focus. Antimicrobial stewardship toolkit for English hospitals.
        PHE, London2011 (updated March 2015)
      1. Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. Available at: [last accessed July 2018].

        • Public Health England
        English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report 2017.
        PHE, London2017
        • Gerber J.S.
        • Newland J.G.
        • Coffin S.E.
        • Hall M.
        • Thurm C.
        • Prasad P.A.
        • et al.
        Variability in antibiotic use at children's hospitals.
        Pediatrics. 2010; 126: 1067-1073
        • Halls A.
        • Van't Hoff C.
        • Little P.
        • Verheij T.
        • Leydon G.M.
        Qualitative interview study of parents’ perspectives, concerns and experiences of the management of lower respiratory tract infections in children in primary care.
        BMJ Open. 2017; 7e015701
        • Department of Health
        Behaviour change and antibiotic prescribing in healthcare settings. Literature review and behavioural analysis.
        DH, London2013
        • Silva A.R.
        • Albernaz de Almeida Dias D.C.
        • Marques A.F.
        • Biscaia di Biase C.
        • Murni I.K.
        • Dramowski A.
        • et al.
        Role of antimicrobial stewardship programmes in children: a systematic review.
        J Hosp Infect. 2018; 99: 117-123
        • McCannon C.J.
        • Hackbarth A.D.
        • Griffin F.A.
        Miles to go: an introduction to the 5 million lives campaign.
        Jt Comm J Qual Patient Saf. 2007; 33: 477-484
        • Department of Health
        UK five year antimicrobial resistance strategy 2013 to 2018.
        DH, London2013
        • Rocha-Pereira N.
        • Lafferty N.
        • Nathwani D.
        Educating healthcare professionals in antimicrobial stewardship: can online-learning solutions help?.
        J Antimicrob Chemother. 2015; 70: 3175-3177
        • Kapadia S.N.
        • Abramson E.L.
        • Carter E.J.
        • Loo A.S.
        • Kaushal R.
        • Calfee D.P.
        • et al.
        The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons learned from a multisite qualitative study.
        Jt Comm J Qual Patient Saf. 2018; 44: 68-74
        • Silverberg S.L.
        • Zannella V.E.
        • Countryman D.
        • Ayala A.P.
        • Lenton E.
        • Friesen F.
        • et al.
        A review of antimicrobial stewardship training in medical education.
        Int J Med Educ. 2017; 8: 353-374
      2. Department of Health. Health and social care act 2008. Available at: [last accessed July 2018].

        • Doernberg S.B.
        • Abbo L.M.
        • Burdette S.D.
        • Fishman N.O.
        • Goodman E.L.
        • Kravitz G.R.
        • et al.
        Essential resources and strategies for antibiotic stewardship programs in the acute care setting.
        Clin Infect Dis. 2018 Mar 26; ([Epub ahead of print])
        • Vaona A.
        • Banzi R.
        • Kwag K.H.
        • Rigon G.
        • Cereda D.
        • Pecoraro V.
        • et al.
        E-learning for health professionals.
        Cochrane Database Syst Rev. 2018; 1CD011736