Table 2 Description of the identified themes

Concerning antibiotic treatment, we follow a simple algorithm, but when things get complicated, we collaborate with the ID-specialists, and intensive care doctors, of course. [Consultant, gastro surgery] (C1)

The ID-specialist is the primary collaborator when treating difficult infectious disease patients

ID-specialists

Colleagues

Working as a resident, I first phone the consultant on call. However, often you end up phoning the resident on call at the department of internal medicine. Occasionally they can give you some advice, or they consult their consultants. A couple of times I have called the ID-specialist at the University hospital. [Resident, oncology] (C2)

When the ID-specialist is not readily available several other colleagues contribute to the choice of AB-treatment; More experienced colleagues in the wards and on call, internists, especially pulmonary doctors and microbiologists can provide input on AB treatment

Other colleagues

We put great effort into obtaining specimens, preferably several specimens, in order to be sure that we use an adequate antifungal and not just Fluconazole. Our experience is that we more frequently, more often use other drugs, but then again, in accordance with resistance data. [Consultant, intensive care] (M1)

Microbiology test results are considered an important contribution to the treatment; Great effort is put into obtaining cultures and to check up on the preliminary results in order to adjust treatment accordingly.

Priority

Microbiology test results

If it has not been transferred to the electronical medical record, it’s not there. But it’s there. They are just waiting for the final resistance data. In other words, the test results are there, but it takes two or three days before they show up on the screen. So maybe.., yes. No, people just need to know that they can make a phone call. [Resident, internal medicine] (M2)

Microbiology reports become available very late to the clinician. The clinician tries to solve this by phoning to the lab, and vice versa.

Availability

Our systems do not let us check up on what tests have been obtained. You actually have to call and ask: “Have you received the specimen so and so?” Or else, you would have to wait for the results for another two to three days. Once it is available, it is shown in the electronical medical record in the section for laboratory results. [Consultant, ID-specialist] (M3)

It’s perfectly okay as long as you use it, you’re safe. No one can hold anything against you as long as you treat according to the guideline. It really makes you feel safe when on call. [Intern, internal medicine] (N1)

When knowledge and experience are insufficient, the guideline is perceived as a useful and supportive tool. The guideline’s significance however decreases with increased experience and knowledge.

Experience

National guideline

Well, I try to stick to the guideline, most of the time. If I do not, I normally have good reasons not to. But, I do not always agree with it. And I try to justify it if I do not follow it. [Consultant, ID-specialist] (N2)

The computer works incredibly slow here. It is very annoying when logging on, that is. You just sit there and twiddle you thumbs for… That’s when it would have been great to have an app, just great. [Intern, internal medicine] (N3)

Suboptimal IT-systems impairs the availability of the guidelines. Distribution on several platforms would promote the availability

Availability

..we have checklists for items they have to check out. And the antibiotic guideline is one among them. That’s how we somehow tell them this is to be complied with, and also to be sure that they know how to find it. [Consultant, internal medicine] (N4)

The guideline is used to promote AB policy

Promoting policy

Education mainly takes place at the end- of- shift meetings, that is. Much is embedded in each of the cases we discuss. [Consultant, orthopedics] (T1)

Training is mainly informal and unsystematic; Lectures are held irregularly. However, training comes mainly from discussing clinical cases and observing more experienced colleagues

Informal and unsystematic

Training

Discussing with ID-specialists, but also observing how other doctors on call treat patients and discussions at the end- of- shift meeting. [Resident, internal medicine] (T2)

There is no scheduled training, no. You’re expected to possess that knowledge, which you don’t have as an intern, because, it’s too theoretical. To have a guideline, -it is presented to you early on.. Just check the guideline, just use it. And you end up reading about it yourself. [Resident, internal medicine] (T3)

The national guideline is used as a substitute for the formal training

Guideline

Sometimes, in the emergency department when your findings are inconclusive, you broaden the initial therapy. They keep telling me: “Try not to use broad spectrum as much,” but once in a while you just have to, and it’s is okay to a certain degree. Patient first, so to speak. [Intern, internal medicine] (P1)

When patient history, findings and diagnostic tools are inconclusive it feels safer to prescribe antimicrobials, than not. For the same reason broad- spectrum therapy often is chosen

Inconclusive conditions

Patient assessment

It depends on clinical judgement, and the patient’s clinical condition. If he is in very bad condition, fulfilling all the sepsis criteria, and has an unstable blood pressure and everything, only the broadest spectrum. [Consultant, urology] (P2)

Severity of disease determines the intensity of treatment; Threshold for starting AB, prescribing broad spectrum agents and prolonging therapy is lowered

Severity of disease

No, I’m not quite sure whether I can call it politically incorrect, but severely ill neutropenic patients are given Meropenem although it’s possible that they shouldn’t be given any antibiotics at all, but at the same time I think that… [Consultant, internal medicine] (P3)

I may have become better at waiting. In most cases, you have much more time than you expect. And in that case, you can wait until you know some more. [Resident, internal medicine] (P4)

Clinical experience facilitates dealing with the challenging conditions and to adopt a restrictive approach in antimicrobial treatment

Clinical experience

No, it’s not on the agenda, that’s my experience. My impression is that we are free to do as we like. But, it doesn’t mean that we can go crazy. I think it would have been pointed out if we were to give everyone everything. I think it would have been put on the agenda. [Consultant, ID-specialist] (L1)

AB policy is to a small extent on the agenda of the hospital leaders

Priority

Leadership

NN is the leader of the infectious disease department, and he is on every end-of-shift meetings and so on. And it’s very.. people always say: “We give this and that, and I’m not sure that the ID-specialists agree.” And they sit there, and give corrections, or say: “Yes, but we have to resort to that,” or.. [Resident, internal medicine] (L2)

The ID-specialists advocates prudent AB use in discussions about clinical cases, typically on morning sessions.

ID-specialists