Healthcare professionals’ concerns.

HCPs concerns that can lead to noncompliance to guideline recommendations regarding vancomycin prescription were categorized into three subthemes:

1. a) Family’s response to stopping antibiotics and the fear of being blamed as a barrier to optimal vancomycin use in real daily clinical practice.

"… the clinical picture and other factors control our use of antibiotics, not just the guidelines; for example, some families are nagging and troublemakers and you (the doctor) are afraid that if you stop the antibiotic and the patient relapses that you would be blamed, so if the kidney function is good, you would keep the patient on vancomycin."

(Participant 11—neurosurgery resident).

1. b) Fear of vancomycin adverse effects

"In the NICU, the problem is that neonatologists don’t usually increase the vancomycin dose to reach a target of 15–20 mg/L even when it is indicated because they are afraid of vancomycin’s toxicity"

(Participant 12—clinical pharmacist)

1. c) Fear of potential undiagnosed infections

"We feel that we overprescribe antibiotics against guideline recommendations. For instance, we know that the case is a case of drug-induced fever or autoimmune disease, but still, we give antibiotics because deep inside you will not be comfortable if the patient needs an antibiotic for some reason and you don’t give it, so frankly we overprescribe antibiotics (vancomycin). We give fluids and take levels to keep the patients safe"

(Participant 18—chief internal resident).

As for TDM, the same resident reported that TDM might be overused in the ICU due to concerns related to the critical situation of patients

"We may perform TDM on a daily basis for ICU patients because they are critical and their kidney function changes continuously, so they need adjustment every day …we do it even if the level is not valid because serum creatinine changes… we also may tell nurses to delay the next dose until we tell them to give it depending on the level results"

(Participant 18—chief internal resident).

Perceived lack of benefit of TDM.

Some HCPs perceived vancomycin TDM as unnecessary, which may lead to noncompliance with TDM guidelines

"Vancomycin TDM is not really necessary. There are more important things to do… you would do TDM for a patient on digoxin, or patients taking neuro-medicines or antipsychotics, for those medications we need to take levels"

(Participant 28 -internal resident).

Negative perception towards prescribing guidelines.

Interview findings revealed that residents and clinical pharmacists seemed to be aware of available international guidelines and support resources for antibiotic prescribing in general and vancomycin in specific and were careful to familiarise themselves with all the evidence and knowledge about vancomycin dosing and monitoring. However, they expressed concerns about the simplicity of guidelines and their lack of updated information.

"We have guidelines, but they are not used, they are outdated, and they don’t include everything"

(Participant 20 -pediatric resident)

"If something is straightforward, we use guidelines, but we don’t see them useful for complicated cases, we rely on experience"

(Participant 7- emergency resident)

Furthermore, another HCP pointed out how prescribers questioned the applicability of evidence from international guidelines to real-world prescribing population, as indicated below:

"We have international guidelines, there are reasons why doctors don’t follow guidelines, their recommendations may contradict their experiences and they may consider that the management of diseases in actual practice in Jordan is different from USA or U.K. because resistance patterns differ"

(Participant 27- pediatric resident).

Lack of guidelines to guide TDM.

HCPs perceived the lack of clarity of guidelines in vancomycin TDM as a barrier to optimal practice:

"Again, the barriers would be the fact that we don’t have clear guidelines here… for changing the dose based on the trough level, we would depend more on the experience, so we might change, for example, the dose by 10–15% of the original dose depending on the case. Actually, there is no fixed ratio."

(Participant 8: internal resident)

Prescribing culture.

The decision to initiate vancomycin is usually made by consultant physicians, especially in complicated cases. However, vancomycin can also be started by residents in simple cases or during night admissions, and then the decision is confirmed by the consultant.

"Consultants along with residents prescribe vancomycin …. It depends on the situation. If I am on a night shift and the case is clear for example, bacterial pneumonia, it is not reasonable to call the consultant in the middle of the night, we start it, and the following day during the round, we finalize the decision….I don’t always agree with consultants regarding their prescription of vancomycin, I think there is abuse"

(Participant 20 -pediatric resident)

Residents expressed their hesitancy to share their concerns regarding vancomycin prescription with consultants and stated that they would just follow the consultant’s recommendation without questioning their judgment, even if they thought that the decision was not correct.

"Residents are responsible for prescription unless in complicated cases… We have a protocol in our NICU unit. Some consultants may give vancomycin even when not indicated. Vancomycin is frequently prescribed (in about 20% of patients). I am not always convinced with vancomycin prescription decisions, we have misused, but I don’t share my opinion with consultants."

(Participant 11: neurosurgery resident)

"If the consultant insists on prescribing vancomycin, we just follow his recommendation even if it doesn’t follow the guideline, we don’t question his judgment"

(Participant 32, internal resident)

Lack of effective communication among healthcare providers.

Ineffective communication between healthcare providers may result in ineffective dose adjustment, delayed doses, or misinterpreted samples.

"As pharmacists, if we have a recommendation about a dose change, we have to communicate with the medical team in charge of the patient, you have to communicate with the senior resident or the consultant, and sometimes this is difficult, and the required recommendation is not implemented"

(Participant 26 -clinical pharmacist)

"As nurses, we suffer until the junior physicians come to do a scheduled sample; you call them and tell them to come, sometimes they come, and sometimes they don’t, and sometimes they come late. So we may do the samples to avoid further delay".

(Participant 9—nurse)

"Sometimes nurses give the dose before we have the chance to take a trough sample, you will not find this in records, and we wouldn’t know unless we have an odd level, for example, your patient’s level is 6-7mg/L daily, suddenly you would find that the level is 50 mg/L. Usually, this gives you an indication that the trough sample was withdrawn at an inaccurate time"

(Participant 10 -internal resident).

Lack of support strategies: On-rotation versus out-of-working hours.

Prescribers declared that they are better supported during working hours either by the availability of consultants or by requesting consultation on the spot from other colleagues. For example, they can refer to infectious disease specialists and clinical pharmacists who may offer prescribing advice for challenging decisions that are not covered in the local antimicrobial guidelines. However, out of working hours and night shifts, HCPs were less supported and had fewer resources.

"During consultant rounds in the morning, there are infectious disease specialists that we can refer to if there is something not clear or if the patient is not responding; this is helpful. However, during night shifts, such support is not available, but we may contact the fellow"

(Participant 10 -internal resident)

"During working hours, I am in the ward, and I provide support regarding appropriate dosing when needed, however outside working hours, there is no communication; I don’t have to answer my phone outside my working hours they may just give a stat dose at the time"

(Participant 22 -clinical pharmacist)

Work pressure and shortage of staff.

Furthermore, for many HCPs, lack of time due to work pressure per se was perceived as a barrier to optimal vancomycin administration. For instance, a nurse revealed that work overload and time pressure would make it easy to make mistakes.

"I don’t justify, it is not a justification, but the reality is something else. For example, as a nurse, you have 4, or 5,6,7 patients on antibiotics. This number is problematic, and work pressure causes stress that generates errors. Errors are usually missed information that is important or risky to the patient."

(Participant 29 -nurse)

The workload was also reported consistently to hinder HCPs from optimal TDM practice.

"it is difficult to adhere to TDM guidelines in terms of accurate recording of the time of dose administration and sample collection. We have a lot of pressure. If we were in a private hospital and each of us handled 2–3 patients, that would be easy. I have to administer medications for 20 patients if we assume that 3–4 patients are on vancomycin it will be difficult to record every dose, there is no time and no staff"

(Participant 14-nurse)

"Some mix-ups in vancomycin TDM may occur due to work pressure. A pharmacist counts the doses of vancomycin once prescribed and marks when vancomycin TDM should be done, but they may miss this mark, or the pharmacist may not mark the medication sheet if vancomycin was started during the weekend, and the TDM may be forgotten. It depends on the degree of work pressure in the ward"

(Participant 17 NICU pharmacist).

Lack of institution-wide training opportunities.

HCPs seemed to have assumed that, in principle, lack of training was a barrier to optimal TDM performance. Interviews with HCPs revealed that they were keen to participate in training workshops that were assumed to support their needs and fill in the gap in current practice.

"I don’t remember receiving any training regarding antibiotics; as you know, this mainly related to physicians, but I remember once we took a lecture about administration, I would like more training about antibiotics and TDM. I think it will be useful"

(Participant 30- nurse)

Logistics.

HCP reported that sometimes logistics might interfere with the efficiency of TDM and the ability to comply with its protocol

"The problem is that multiple staff is involved in the process of TDM, and this confuses things, sometimes I can’t do my job because the porter didn’t take the sample to the lab…sometimes this has delayed my work for 4 hours, it is not easy to go by the book in actual practice"

(Participant 1 -clinical pharmacist)

Provide training sessions.

Overall, there seemed to be a general sense of the need for training sessions for HCP. Most HCPs suggested that providing education and training in vancomycin dosing and monitoring might have the potential to increase their knowledge and confidence during their daily practice.

"There must be continuous training, especially for staff working with pediatrics as their doses are small and not easy to prepare also we see a lot of side effects such as red man syndrome, more training would be useful"

(Participant 3—nurse).

Provide a decision support system.

HCPs seemed to have assumed that, in principle, the use of decision support systems would be useful and could potentially improve adherence to TDM guidelines to support their needs and fill in the gap in current practice.

"I think any sort of computerized program is good, as far as it has an alarm system that reminds you of the samples that must be drawn for your patient, and a calculator where you put patient’s characteristics, and it gives you the new dose, so it’s more organized and more structured… it will be good …"

(Participant 10 -internal resident)

Moreover, a clinical pharmacist suggested that such a system would be useful for HCPs who are not familiar with doing vancomycin calculations.

"We took a course about vancomycin calculations, but we didn’t complete it. We do the calculations based on the equations we took at the university, and I don’t feel confident doing them alone. If there is a support system, it would be useful.

(Participant 22 -clinical pharmacist)

Activating the role of clinical pharmacist.

HCPs explicitly referred to the potential role of clinical pharmacists in the vancomycin prescribing process. For instance, a resident spoke from her experience, as indicated below:

"I feel that it is very useful that we have a clinical pharmacist in NICU. She always reviews the medication sheet, checks the levels, and checks the doses of babies because their weight changes day by day, so she follows up on increasing or decreasing doses for each patient and checks the duration of therapy. As a resident, I am very busy, so I can’t catch up on everything they help us. Honestly, I feel that it is very important to improve practice to have a clinical pharmacist in every ward; this is what I am sure of. In NICU, their presence is very helpful"

(Participant 7: pediatric resident)

"I think clinical pharmacists must be more involved in medication reconstitution, especially those that need to be prepared under sterile conditions, we are under a lot of pressure, and they are more knowledgeable regarding drugs and their interactions. I think it would be helpful if they were more involved in drug preparation, including vancomycin. That would be very helpful to us".

(Participant 3 –nurse)

Need for national guidelines and protocols.

HCPs highlighted the need for local guidelines and protocols that would potentially support their prescribing practice performance.

"I think it would help if there are local guidelines and protocols based on local antibiograms. This would always be helpful to improve practice."

(Participant 20 -paediatric resident)

An HCP also said that the availability of local guidelines would potentially improve their vancomycin prescribing by reducing variation in vancomycin treatment and management and helping to streamline clinical workflows.

"….it also standardizes the practice. It is very important, help to streamline workflow"

(Participant 18 –chief internal resident)