Failure to implement hospital antimicrobial prescribing guidelines: a comparison of two UK academic centres

Background: Rational antimicrobial therapy should provide maximum benefit to patients while minimizing the development of resistant microorganisms. Objectives: The aim of this study was to investigate (i) which antimicrobial drugs were chosen by hospital doctors faced with two common infections [community-acquired pneumonia (CAP) and urinary tract infection (UTI)], (ii) whether these choices were compliant with local guidance and (iii) the factors that influenced antimicrobial choice. Methods: A questionnaire based on two hypothetical clinical scenarios was distributed to 316 hospital doctors across four UK NHS hospitals in two cities (Newcastle and Edinburgh). Results: Doctors in Newcastle were significantly more aggressive in their management: more patients were admitted (CAP: 78.9% versus 48.4%, P < 0.05) and given antimicrobials intravenously (CAP: 53.4% versus 21.2%, P < 0.05). Adherence to the local hospital guideline for CAP was significantly higher in Newcastle (83.3% versus 38.0%; P < 0.05). Fewer than half of the doctors surveyed used the local hospital guideline when choosing an antimicrobial, and the British National Formulary was the most frequently used resource (> 90%). Junior doctors also identified medical school teaching and opinions of senior doctors as important influences. Conclusions: This study highlights inadequacies in the implementation and promotion of local guidelines, and demonstrates the potential for widely varying antimicrobial practices in two comparable UK cities.