"#$#%#&'#(:

8erendL 1, !effcoaLe W, Llpsky 8A. 2007. Challenges, goals and sLraLegles for Lhe nexL 10 years. !"# %&'(#)&* +,,) -,./0'1 10(4): 190-92
8[rkman l, 8erg !, 8lng M, LrnLell M, Lundborg CS. 2010. ercepLlons among Swedlsh hosplLal physlclans on prescrlblng of anLlbloLlcs and anLlbloLlc reslsLance. 2.'1&)3 4'5#)3 6#'1)" 7'/# 19:e8 dol:10.1136/qhsc.2008.029199llncke eL al 2010. varlaLlon ln anLlbloLlc LreaLmenL for dlabeLlc
paLlenLs wlLh serlous fooL lnfecLlons: A reLrospecLlve observaLlonal sLudy. 897 6#'1)" 4#/:&*#; <#;#'/*"= >?@>AB
Colalzzl, . 1978. sychologlcal research as a phenomenologlsL vlews lL. ln 8. valle & M. klng(Ld), CD&;)#0)&'1EF"#0,G#0,1,H&*'1 '1)#/0')&:#; 5,/ F;3*",1,H3I new ?ork:Cxford unlverslLy ress.
llncke eL al 2010. varlaLlon ln anLlbloLlc LreaLmenL for dlabeLlc paLlenLs wlLh serlous fooL lnfecLlons: A reLrospecLlve observaLlonal sLudy. 897 6#'1)" 4#/:&*#; <#;#'/*"= >?@>AB
Lavery AL et al. 2007.Validation of the Infectious Diseases Society of Americas Diabetic Foot Infection Classification System. 71&0&*'1 J05#*)&,.; %&;#';#; 44:362-3
owers !P. 2009. 8lsk ercepLlon and lnapproprlaLe AnLlmlcroblal use: ?es, lL Can PurL. 71&0&*'1 J05#*)&,.; %&;#';#; 48: 1330-3.



I tend to use more prolonged courses than
perhaps other people would suggesthistory
and experience would tell me thats what you
need (ConsulLanL hyslclan).
)*%+,',-*&+(
SevenLeen speclallsL hosplLal cllnlclans lncludlng ConsulLanL hyslclans, SpeclallsL 8eglsLrars,
ConsulLanL MlcroblologlsL, SpeclallsL odlaLrlsLs, ConsulLanL vascular Surgeons.
Clinicians Perceptions of Prescribing Antibiotics for Infections in the Diabetic .//+
uebble Sharman, ConsulLanL odlaLrlsL ulabeLes
uebble.sharman[dhufL.nhs.uk
0+123 4,5( 6 2#(,7&
1hls sLudy ls concerned wlLh Lhe F#/*#F)&,0; of cllnlclans wlLh regard Lo Lhe prescrlblng of anLlbloLlcs
for dlabeLlc fooL lnfecLlons. 1he prlmary ob[ecLlve ls: Lo explore and descrlbe experlences and vlews
regardlng Lhe cllnlcal managemenL of lnfecLlons among speclallsL cllnlclans lnvolved ln Lhe
managemenL of Lhe dlabeLlc fooL.

Secondary ob[ecLlves:
1o explore percepLlons and awareness of anLlbloLlc reslsLance.
1o explore wheLher Lhere are any unknown facLors LhaL may conLrlbuLe Lo Lhe non-pharmacological
prescrlblng of anLlbloLlcs.

A phenomenologlcal approach was used, wlLh daLa collecLed ln face Lo face lnLervlews.
8*'97%/1&2
looL wounds are among Lhe mosL common and severe compllcaLlons of dlabeLes. AbouL half of all Lhese wounds become cllnlcally lnfecLed, Lhe severlLy of Lhese lnfecLlons ranglng from mlld Lo llmb- and even llfe-LhreaLenlng
(Lavery eL al 2007). lnfecLlon ls an lmporLanL conLrlbuLor Lo Lhe chronlc morbldlLy assoclaLed wlLh Lhe dlabeLlc fooL and as an lmmedlaLe precedenL Lo ampuLaLlon (8erendL 1, !effcoaLe W, Llpsky 8A. 2007).
Lack of consensus abouL opLlmal LreaLmenL means LhaL Lhere ls subsLanLlal laLlLude ln Lhe cholce of boLh wheLher or noL Lo prescrlbe anLlbloLlcs, and whlch anLlbloLlcs Lo prescrlbe for dlabeLlc fooL lnfecLlons, wlLh Lhe llkely resulL
LhaL Lhere wlll be subsLanLlal varlaLlon ln pracLlce (llncke eL al 2010).
Some prescrlbers glve anLlmlcroblals Lo paLlenLs uslng Lhe maxlm it cant hurt, based on Lhe mlsLaken assumpLlon LhaL Lhe use of anLlmlcroblals comes aL no cosL Lo Lhe paLlenL or socleLy (owers 2009). 8[rkman and
colleagues (2010) have descrlbed several proposed facLors LhaL lnfluence anLlbloLlc prescrlblng and suggesLed LhaL a declslve facLor ls how prescribers percepLlons subsequenLly lnfluence Lhelr behavlours.
:*+* 4&*;3(,(
Lach lnLervlew LranscrlpL was examlned llne by llne Lo ldenLlfy phrases or senLences LhaL dlrecLly perLalned Lo Lhe
lnvesLlgaLed Loplc, whlch were hlghllghLed wlLhln Lhe LexL. 1he LranscrlpLs were Lhen revlewed agaln, noLlng down Lhe
meanlng of each slgnlflcanL sLaLemenL (Colalzzl 1978).

When Lhls had been compleLed for all sevenLeen LranscrlpLs, a llsL was made of all Lhe emerglng Lhemes or formulaLed
meanlngs. 1he frequency of whlch each Lheme was menLloned by respondenLs was recorded. 1he Lhemes were Lhen
analysed and clusLered lnLo loglcal groups.
"#(1;+(
A LoLal of 132 slgnlflcanL Lhemes were ldenLlfled whlch were
Lhen clusLered lnLo 10 Lheme groups:
AnLlbloLlc reslsLance
ApproprlaLe use of anLlbloLlcs
When Lo prescrlbe / sLop anLlbloLlcs
lnfluences on prescrlblng
CompllcaLlons / areas of concern
Mlcroblology
uuraLlon of LreaLmenL
MulLl-dlsclpllnary Leam (Mu1)
1ralnlng / experlence
CLher facLors
:#',(,/&( <1,2,&7 :,*=#+,' .//+ >&$#'+,/& ?*&*7#5#&+



Weve H,) ), (# *,0;)'0)13
vigilantWe all have to be very
/#;F,0;&(1# &0 G&0&G&;&0H )"#
/&;K ,5 /#;&;)'0*# (3 L.M&*&,.;
use (ConsulLanL hyslclan).

One of the biggest tools
)"') J .;# &; *1&0&*'1
L.MH#G#0) 5/,G
experiencethe best
L.MH# ,5 M./')&,0 ,5
'0)&(&,)&* )"#/'F3 &;
M&/#*)13 F')&#0) (';#M
and clinically judged
(ConsulLanL hyslclan).
Youre relying on someone
elses experience E G3
F/#;*/&(&0H "'; ,5)#0 (##0 1#M
by the podiatrist (ConsulLanL
hyslclan).
I think diabetic F')&#0);= &0 G3
#DF#/&#0*#= ;##G ), )'K# 1,0H#/ ),
/#;F,0M= F/,('(13 (#*'.;# ,5 )"#
ischaemic nature of the feetthey seem
to require longer courses (ConsulLanL
MlcroblologlsL).
Knowing the opinion of the
podiatristits very useful (SpeclallsL
8eglsLrar).
The nurses or GPs dont appreciate
",N ;#:#/# ' M&'(#)&* 5,,) &05#*)&,0
/#'113 &; '0M G'3(# .0M#/EF/#;*/&(# )"#
doses and dont prescribe them for long
enough (odlaLrlsL).
It may require a higher
M,;# &0 ' M&'(#)&*= &0
,/M#/ ), '*"&#:#
'M#O.')# 1#:#1; ') )"#
site of infection
(ConsulLanL
MlcroblologlsL).
From my point of view, theres a 1,) ,5
ignorance about what to dowhats the
/&H") )"&0H ), do (ConsulLanL Surgeon).
Factors influencing decision making
0 2 4 6 8 10 12 14 16 18
Decision to prescribe
Choice of antibiotics
Decision to change
treatment
Decision to stop antibiotics
Dosage decisions
Duration of treatment
I
n
f
l
u
e
n
c
e

o
n

d
e
c
i
s
o
n
number of responses
Fear / anxiety
Influence of previous treatment
Influence of Patient factors
Influence of regular review
Guidelines / evidence
Opinion of others
Influence of Confidence
Experience
Influence of Clinical judgement
Compliance issues
Influence of Clinical picture
Influence of Test results
.,&2,&7(@
Several slgnlflcanL core concepLs have emerged from Lhe sLudy. All cllnlclans dlsplayed a sLrong awareness of Lhe lssue of anLlbloLlc reslsLance, buL dld !"# feel it was a significant problem in the diabetic foot population of patients. However,
along wlLh Lhe rlsk of slde effecLs (also reporLed as causlng mlnlmal harm), lL was clLed as Lhe maln reason for wanLlng Lo Lry and mlnlmlse Lhe duraLlon of anLlbloLlc use. uesplLe Lhls, long duraLlons of Lherapy were consldered Lo be necessary
wlLhln Lhls paLlenL cohorL, along wlLh Lhe acknowledgmenL LhaL anLlbloLlcs were posslbly overused.
ManagemenL of dlabeLlc fooL lnfecLlon was felL Lo be complex and mulLl-facLorlal. AnLlbloLlcs were consldered essenLlal for Lhe LreaLmenL of lnfecLlon, buL were [usL one elemenL of managemenL. ulabeLlc paLlenLs were consldered by mosL
clinicians to be different from their non-dlabeLlc counLerparLs, requlrlng a dlfferenL LreaLmenL approach.
1he value of Lhe mulLl-dlsclpllnary Leam and shared declslon-maklng was wldely reporLed. ulfflculLles ln accuraLely dlagnoslng lnfecLlon, or assesslng wheLher lnfecLlon had compleLely resolved meanL LhaL cllnlclans frequenLly dlscussed on-
golng treatment with colleagues; providing verification and a form of quality assurance .
aLlenL facLors were wldely reporLed as belng very lnfluenLlal, parLlcularly when lL came Lo maklng a declslon regardlng whlch drug Lo prescrlbe.
lear or anxleLy of adverse ouLcomes, ls a domlnanL facLor ln declslons regardlng Lhe duraLlon of Lherapy. Several cllnlclans were prepared Lo admlL LhaL Lhey posslbly conLlnued wlLh anLlbloLlcs for longer Lhan mlghL be necessary due Lo
anxleLles over sLopplng LreaLmenL.
A/&';1(,/&(@
1hls sLudy presenLs a new way Lo undersLand how speclallsL cllnlclans percelve anLlbloLlc prescrlblng ln Lhe managemenL of dlabeLlc fooL lnfecLlon.
Cverall, Lhere appears Lo be a large degree of consensus ln how Lhls complex condlLlon ls managed, desplLe a lack of good quallLy Lrlal evldence Lo
gulde pracLlce. Cllnlclans reporL Lhe value of Lhe mulLl-dlsclpllnary fooL care Leam and Lhe lmporLance of shared declslon maklng. 1here ls
acknowledgemenL LhaL anLlbloLlcs may be prescrlbed for longer duraLlons Lhan may be absoluLely lndlcaLed, underplnned by a fear of devasLaLlng
consequences lf lnfecLlon ls noL adequaLely managed. 1here ls a bellef LhaL currenL pracLlces do noL lead Lo excesslve harm ln Lerms of anLlbloLlc
reslsLance and slgnlflcanL adverse effecLs. Cenerally, cllnlclans also feel Lhere ls lnsufflclenL currenL evldence Lo provoke a change Lo Lhelr currenL
managemenL sLraLegles.
AnLlbloLlcs are noL percelved Lo be used lndlscrlmlnaLely, and careful conslderaLlon ls glven Lo Lhelr use.
Lxperlence and cllnlcal [udgemenL are seen as Lhe ma[or Lools avallable ln Lerms of managlng dlabeLlc lnfecLlon. 1here was a Lendency for more senlor
or experlenced cllnlclans Lo express Lhls, whllsL more [unlor cllnlclans were more llkely Lo wanL guldellnes. 1here ls concern regardlng Lhe lack of
knowledge among more [unlor cllnlclans and non-speclallsL sLaff. 1ralnlng wlLhln Lhls speclallsm ls very llmlLed and consldered Lo be a facLor ln paLlenLs
recelvlng sub-opLlmal care ouLslde of Lhe speclallsL Leam.

"#'/55#&2*+,/&( $/% $1%+B#% -%*'+,'#@
ulscusslon of resulLs wlLhln Lhe speclallsL mulLl-dlsclpllnary
Leams and conslderaLlon of an acLlon plan Lo gulde pracLlce,
CompleLlon and dlssemlnaLlon of a locally agreed dlabeLlc fooL
anLlbloLlc guldellne,
AudlL of local anLlbloLlc reslsLance and ClosLrldlum dlfflclle
lncldence among dlabeLlc fooL paLlenLs,
Development of a training package and guidelines for junior
docLors / speclallsL reglsLrars (ln-house and aL a faculLy level),
lmproved awareness / Lralnlng ln general pracLlce,
lurLher sLudy lnLo lssues surroundlng paLlenL compllance /
concordance.