Factors influencing uptake of evidence-based antimicrobial prophylaxis guidelines for electrophysiology procedures

Abstract

Clinical guidelines support early discontinuation of antimicrobials after cardiac device procedures; however, prolonged courses of antimicrobials are common. We conducted semistructured interviews with 13 electrophysiologists representing diverse geographic and clinical settings of care to identify perceived barriers and facilitators to discontinuing postprocedure antimicrobial prophylaxis as part of a formative evaluation prior to implementing a program to improve uptake of guideline recommendations. A directed content analysis approach was used to map responses to the Implementation Outcomes Framework. Data indicated that electrophysiologists were not willing to stop postprocedural antimicrobials, indicating a lack of acceptability of clinical guidelines. Feasibility, fidelity, cost, and appropriateness were also frequently cited. Factors associated with prolonged antimicrobial prescribing included beliefs about lack of harm and possible benefit. There was a strong "cultural inertia" to conform to institutional normative practices. Reasons for conforming ranged from streamlining processes for clinical staff and concerns about being perceived as an "outlier." Institutional culture and beliefs about consequences of cardiac device infections versus antimicrobial use appeared to be major drivers of current practice. The desire to promote institutional standardization suggests that strategies to enhance implementation of prophylaxis guidelines must include facility-level changes, rather than interventions directed only at individual-providers.