Antibiotic prescribing by physicians in primary care institutions is common and affected by several factors. Diagnosis and treatment of infections in a nursing home (NH) resident is challenging, with the risk of both under- and overtreatment. Identifying barriers and facilitators of appropriate antibiotic prescribing in NHs and municipal acute care units (MACUs) is essential to ensure the most adequate antibiotic treatment possible and develop future antibiotic stewardship programs.n = 11) and nurses (n = 14) in 10 NHs and 3 MACUs located in the county of Østfold, Norway. We used a semi-structured interview guide covering multiple areas influencing antibiotic use to identify persistent barriers and facilitators of appropriate antibiotic prescribing after the intervention. The interviews were audio-recorded and transcribed verbatim. The content analysis was performed following the six phases of thematic analysis developed by Braun and Clarke.After implementing a one-year antibiotic quality improvement program, we conducted six semi-structured focus group interviews with physicians (We identified thirteen themes containing barriers and facilitators of the appropriateness of antibiotic use in primary care institutions. The themes were grouped into four main levels: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level. Unclear clinical presentation of symptoms and lack of diagnostic possibilities were described as essential barriers to appropriate antibiotic use. At the same time, increased availability of the permanent nursing home physician and early and frequent dialogue with the residents’ next of kin were emphasized as facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process regarding infection diagnostics and treatment was by both professions described as profound.Our qualitative study identified four main levels containing several barriers and facilitators of appropriate antibiotic prescribing in Norwegian NHs and MACUs. Diagnostic uncertainty, frequent dialogue with next of kin and organisational factors should be targeted in future antibiotic stewardship programs in primary care institutions. In addition, for such programs to be as effective as possible, nurses should be included on equal terms with physicians. Antimicrobial resistance is an increasing challenge worldwide , and thePrescribing antibiotics can be classified either as medically or ethically appropriate based on the circumstances of the specific antibiotic-requiring infection. Medically appropriate antibiotic use typically covers the clinical, microbiological, pharmacokinetic and dynamic aspects of the specific cases. Simultaneously, antibiotic treatment among old and frail NH residents is primarily about prolonging life, which raises the question of whether antibiotic treatment is appropriate or inappropriate from an ethical perspective. Ethical questions make infection diagnostics and treatment a more significant challenge for NH physicians and nurses, as multiple comorbidities, polypharmacy, speech and hearing disabilities, cognitive debilitation, and atypical symptom manifestation of infections is more common in the NH population –15. LimiAlthough the final decision to prescribe antibiotics or not is taken by one or several medical physicians, the decision-making of prescribing is multifactorial and complex. Previous studies have identified several factors influencing antibiotic prescribing in hospitals and general practice, for example, physician-specific and patient-related factors, availability of diagnostic tools and local antibiotic resistance data, patient satisfaction and cultural and organizational factors –31. ManyResponding to the emerging antimicrobial resistance threat, the Norwegian Government published its “National Action Plan against Antibiotic Resistance in the Health Services” in 2016 . As partPrevious Norwegian studies have found a wide variation in total antibiotic use between Norwegian NHs, indicating a potential for improving antibiotic prescribing in this sector , 40. In “Standards for Reporting Qualitative Research (SRQR): 21-items checklist” [This article conforms to the ecklist” .The current study was initiated after completing the “RASK” intervention in Østfold county, located in the South-Eastern part of Norway, which lasted from October 2016 to October 2017. In Norway, NHs may be classified as long-term, short-term or mixed (both long- and short-term) based on the residency. In addition to ordinary NHs, we have municipal acute care units (MACUs) to alleviate the use of hospital services. Although classified as a part of the NH sector, MACUs differ from traditional NHs in that the patients live at home and are admitted due to acute onset disease by general practitioners during regular working hours and out-of-hours. When the patients have been treated, they are usually discharged home.We invited all 37 NHs and MACUs in the county to the intervention, resulting in 34 institutions participating in the project. NH and MACU physicians, nurses and other healthcare professionals from included institutions were then invited to a one-day conference with professional presentations and workshops on infections and appropriate use of antibiotics. All participating institutions received a report presenting their antibiotic use based on sales statistics from supplying pharmacies, compared to other participating institutions in the county. After the starting conference, participants were instructed to arrange educational activities on the same topics for their colleagues and set a goal for their institution during the one-year project period. In addition, the institutions were asked to register bi-monthly point prevalence surveys on antibiotic use and indication, and tailor-made clinical checklists were offered as tools to be used during the intervention year. Follow-up conferences were held after six and 12 months, and participating institutions received new antibiotic reports for further academic audit and feedback. All physicians and nurses working in the NHs or MACUs that took part in the intervention were invited orally at the final “RASK” conference to participate in the current study, and in addition they were personally invited by email or telephone. Willing informants were included until we decided that a saturation point had been reached. The saturation point was assessed continuously by comparing the current interview with summaries and transcripts of previous interviews, and decided upon when no new themes and no additional information on pre-existing themes occurred. We conducted six focus group interviews between October 2017 and December 2018 with 11 physicians and 14 nurses from 13 institutions. The participants did not work in the same institution, except from one interview where one physician and three nurses were employed at the same MACU ward. Nine physicians and six nurses had participated at one or more conferences during the intervention year, and all participants were familiar with the programme through the antibiotic reports, educational material, and the use of intervention tools at the institutions. Each focus group consisted of three to six participants, a size range decided upon to obtain interactive group discussions during the interviews and to increase the involvement level for each participant. Four of the interviews were conducted with both physicians and nurses mixed to explore the dynamics between the two occupational groups. The two last interviews were conducted with only physicians in one interview and only nurses in the other to see if we received other information when the groups were interviewed separately.NJH is a part time NH physician working at a short-term NH in one of the municipalities that participated in the “RASK” intervention. In addition, he was the responsible coordinator for the “RASK” intervention in the county of Østfold. NJH had no experience in qualitative research prior to conducting the current study. ML is a long-time GP and a researcher in the field of antibiotic prescribing in general practice and NHs, and had the overall leadership responsibility for the “RASK” intervention in Østfold. MR is a GP and a long-time researcher in the field of NH medicine and general practice. Both ML and MR have extensive prior experience and training in conducting qualitative research. All authors share a common interest in quality improvement in primary care institutions, and factors affecting antibiotic prescribing in particular. Based on the authors background, one could imagine that the informants would formulate their answers based on what they thought was expected to be answered. However, we perceived the discussions in the interviews as open and rich, and that the health personnel talked uncensored about their thoughts, experiences and dilemmas in their clinical work. The prior knowledge of the organizational structure and clinical everyday life rather was an advantage in penetrating and understanding the informants’ stories and perceptions.The interview duration varied from 56 minutes to 87 minutes, with a mean overall duration of 75 minutes. NJH was the main interviewer in all six interviews, while ML and MR participated as co-interviewers in one and five interviews, respectively. We used a semi-structured interview guide that NJH, MR, and ML developed. The interview guide contained four main topics; 1) factors influencing physicians’ antibiotic prescribing, 2) factors influencing physicians’ choice to deviate from antibiotic guidelines, 3) influence of nurses on physicians’ antibiotic prescribing and 4) what ethical dilemmas physicians and nurses experience regarding antibiotic treatment. The informants were provided with written information about the main topics of the study by email in advance. All interviews were started by shortly describing the main topics, followed by encouraging the informants to describe two experienced cases where antibiotic treatment had been initiated; one where there had been no doubt and the other where there had been hesitations regarding the treatment. The main topics were then presented to the informants step-wise through the interviews to initiate discussions in the group. The informants were moderated if they deviated greatly from the topics. When saturation on the relevant topics became evident, the interviewers moved on to the next topic in the interview guide. The interviewers also engaged informants who were not as involved in the discussions and complemented with in-depth questions along the way as needed.The interviewers discussed the interviews immediately after completion of each interview, and a summary for each interview was written and discussed further by email. All interviews were audio-recorded and transcribed verbatim. We based the analyses on the six phases of thematic analysis developed by Braun and Clarke , primariAll participants provided written consent prior to the interviews. We replaced any names and places with numbers and characters in the transcribed text to protect the anonymity of the participants. The Regional Committees for Medical and Health Research Ethics of South-East Norway granted ethics approval for the study (ref.: 2017/1711), and the Norwegian Centre for Research Data approved data protection .The demographic characteristics of the informants are presented in Table We identified thirteen themes grouped into four main overarching levels affecting antibiotic use during the analysis, ranging from individual to external and systemic factors Fig. . Most ofPhysician, male, 35 - 39 years: “They do not have the clear urinary tract infection symptoms. They can be agitated and have a positive urine stick. Instead of starting up with haloperidol or something similar, it is after all a bit better to give a course of pivmecillinam to check if a urinary tract infection is the cause. Therefore, you treat a little more on vague indications.”Unclear clinical manifestations caused by infections, especially in cognitively impaired residents, were regarded as major contributors to diagnostic uncertainty and difficult treatment decisions. Some physicians highlighted the difficulty of distinguishing viral from bacterial respiratory tract infections, due to a perception that frail and old residents with viral respiratory tract infections often present with typical hallmarks of bacterial infections like fever, crackles over the lungs and increased C-reactive protein concentrations. Identifying bacterial aetiology was pointed out as a relevant challenge, especially during flu seasons, which often led to uncertainty among physicians regarding the initiation of antibiotics. In such cases, the resident’s general condition was described as decisive for whether antibiotic treatment should be initiated. Several physicians described that they had a lower threshold for starting antibiotic treatment in residents with a chronic obstructive pulmonary disease when in doubt about the microbiological cause of the respiratory infection. Diagnosis and treatment of urinary tract infection (UTI) was perceived as challenging, especially in demented residents, due to non-specific symptoms, poor anamnesis and high prevalence of asymptomatic bacteriuria, leading to a high level of uncertainty. Both physicians and nurses described several approaches to uncertain UTI situations, including watchful waiting, intravenous fluid therapy and antibiotic prescribing to be on the safe side. With uncertain focus of infections, several of the physicians and nurses described that broad-spectrum antibiotics were often prescribed to cover both the airways and urinary tract system. One of the physicians claimed that in cases where residents presented with new-onset non-specific symptoms, like confusion and agitation, it was better to try a short-term course of antibiotics than more side-effect burdened medications.Physician, male, 35 – 39 years: “We are first-line service, so we do not have all the diagnostic tools. When you get a case with no clear clinical focus, and you have not performed a good advance care planning, I feel a bit trapped. I do not want to refer the patient to the hospital, but still you want to feel that what we do is justifiable. Then it happens that you end up with broad spectrum (antibiotics), and it is often with a bit of distaste, right?!”Among the nurses, a primary concern was an often prolonged time from sampling to blood biochemistry and bacteriological cultivation results. This was regarded as a barrier to treating infections in accordance with the National guidelines for antibiotic use and, potentially, leading to decisions not to prescribe the recommended first-line antibiotics.Lack of diagnostic possibilities was described as a general barrier for both the diagnostic process and for the choice of antibiotic by both professions. On-site x-ray was an opportunity they missed, mainly when dealing with emerging cases of respiratory infections to avoid unwanted and burdensome referrals to the local hospital. One physician described a case that involved a resident who had experienced several respiratory infections, leading to multiple antibiotic treatments. After referring the resident to an x-ray investigation at the hospital, lung cancer was identified. The informant emphasized that the resident could have been spared from many antibiotic courses if inhabiting an on-site x-ray at the NH. The lack of diagnostic possibilities were also described as a barrier for narrow-spectrum antibiotics, as it often led to a “better safe than sorry” approach.Physician, male, 40 – 44 years: “The next day the C-reactive protein has risen, but the fever has gone down and the patient is out of bed. Then there are some who think that the antibiotics does not work … and then... then you have to quickly sign up for a course and start paying attention.”Both professions emphasized increased knowledge regarding the correct use of diagnostic tests as one of the most important measures of the intervention. In particular, the indication and interpretation of urine dipstick and C-reactive protein tests were mentioned.The physicians and nurses pointed to a shortcoming of knowledge, mainly amongst auxiliary nurses and registered nurses, regarding indication, sampling and interpretation of point-of-care test results as a persistent and major barrier to appropriate antibiotic treatment of residents. Not interpreting the test results alongside the clinical signs and symptoms was described as a recurrent problem in the diagnostic process.Physician, female, 40 – 44 years: I gave the introductory antimicrobial resistance lecture, from the first conference meeting, to my nurses. When they saw the maps changing color throughout Europe, from mainly green to mainly red countries, there was a gasp from the assembly. Therefore, I think with good and correct knowledge it at least makes it easier and safer for me to explain and justify my choices to my colleagues.To increase awareness among healthcare professionals, concerning own antibiotic prescribing practices and the development of antimicrobial resistance  was described as an additional intervention measure to facilitate prudent antibiotic use.Physician, male, 35 - 39 years: “When speaking of UTIs, which is where perhaps the most disagreement is, I think if I am in doubt "yes, we’ll send it for culture". It takes a few days or a week until the culture is ready, and by that time the resident has become better or has developed more clear symptoms. Then I gain some time on it, and can postpone or avoid antibiotics.”Some nurses and physicians described the clinical checklist for suspected UTIs, offered to the participating institutions as part of the intervention, as a valuable and effective tool in reducing the number of antibiotic treatments in pending cases of UTIs. One perceived reason for this was that the threshold for sampling urinary dipstick tests increased amongst both auxiliary and registered nurses, leading to fewer tests being presented to the physician for evaluation. Finally, a referral system to the local hospital for diagnosis, treatment decision and level of care, informally called a “diagnostic loop referral”, was highlighted as an additional strategy when dealing with diagnostic uncertainty. This system was mainly utilized by the informants working at MACUs, and to some extent by the NH informants.The physicians and nurses mentioned several strategies to counteract diagnostic uncertainty and thereby facilitate appropriate antibiotic use. Watchful waiting, often combined with intravenous fluid treatment, was described as a commonly used strategy, especially when dealing with suspected but uncertain UTI cases. Utilization of a urine culture to avoid unnecessary antibiotic treatment was additionally lifted as a strategy when encountering non-specific UTI symptoms.One of the physicians described the balancing act of antibiotic treatment in NH residents, and hence life-prolonging treatment, as operating in “gray areas”.Nurse, female, 35 – 39 years: “We have demented residents who say: "No, I am now so ill that this is not compatible with life". And it's a bit like, what do you express in your own illness when you are there? We have demented pneumonia patients who can answer us: "Yes, thank you. It's nice that the doctor has been here, but I will not take any pills". Then you have those who want treatment for all it is worth.”Both professions expressed that if a consent-competent resident, and to some extent consent-incompetent residents, express a specific wish not to be treated with antibiotics in case of a life-threatening infection, the residents wish was usually respected. Nevertheless, some nurses described that it was not unusual that physicians still initiated antibiotic treatments against the residents wish not to receive treatment. Several factors were perceived as barriers to good judgment and decisions regarding antibiotic treatment in end-of-life situations. These included poor advance care planning, lack of residents own voice, cognitive impairment, and residents changing their minds regarding antibiotic treatment during an ongoing infection. Nevertheless, according to both nurses and physicians, such cases often culminated in antibiotic treatments.Physician, male, 35 – 39 years: “Then you have that “fresh product” as you mentioned earlier, where you have a patient who earlier said it does not want any life-prolonging treatment. Then the patient gets an infection and then they want treatment, and then they get (antibiotic) treatment.”Most of the nurses and physicians described an increased focus on assessing consent competence in NHs in recent years. In addition, several of the physicians and nurses emphasized the importance of the patients’ voice regarding antibiotic treatment, even if cognitively impaired and apparently consent incompetent.Physician, male, 35 – 39 years: “If the measure you take to live longer takes away the quality of life....”Physician, male, 40 – 44 years: “Then it may not be the right measure.”One physician shared that many antibiotic treatment courses in NHs are both medically and ethically inappropriate, as it often prolongs residents’ suffering. According to the same physician, the reason for this, and hence being a barrier to proper antibiotic treatment in these situations, was that physicians refuse to decide to refrain from treatment as it is perceived as unpleasant. Furthermore, that the prescriber should assess the level of frailty and underlying disorders before initiating life-prolonging antibiotic therapy and reflect on the life situation the resident eventually would return to, given a successful treatment. Achieving this, according to the same physician, would facilitate both the medically and ethically appropriateness of antibiotic therapy in NH residents. The same physician also applied this to residents experiencing recurring bacterial infections and in cases where the preferred antibiotics lacked effect, leaving the question of whether to change to broader spectrum antibiotics or not.Physician, male, 40 – 44 years: “You have the option to start with penicillin, then it does not work so you add gentamycin, and if that does not work you switch to cefotaxim. If you choose that road, it is clearly not the right way to go with someone that frail in the first place. Although you might do it correct medically, you are ethically completely out of your mind.”Antibiotic treatment of palliative and pre-terminal residents with short life expectancies generated mixed responses. Several physicians expressed a tendency to treat palliative care residents with antibiotics primarily with a symptom-based, not life-prolonging, approach to relieving pain and discomfort associated with the infection. On the other hand, the majority of both nurses and physicians described a clear reluctance towards treating pre-terminal patients with antibiotics, including treatment to relieve symptoms.Physician, female, 35 – 39 years: “It seems directly unethical really. If you think they will die in a short time, giving antibiotics, I do not know. There are also side effects. I cannot see many situations where it can be justified.”One decisive factor that was perceived as crucial regarding life prolonging treatment or not, including antibiotic treatment, was residents’ quality of life. Several different factors influencing quality of life were mentioned, such as familiar joys, a wish to experience important events , or simply to enjoy good food. When evaluating the quality of life, the physicians and nurses expressed that this was an assessment preferably done by residents themselves. In cases with an absent resident voice, both professions described that they usually involved next of kin to elicit information regarding the resident’s earlier preferences. If the involvement of the next of kin did not provide adequate information, the choice of treatment was to be decided by the responsible physician. One physician described that degree of cognitive impairment, pain and agitation were the most essential prerequisites for assessing the quality of life in residents unable to communicate themselves. There was a a general agreement among both nurses and physicians throughout the interviews that antibiotic treatment at the expense of residents’ quality of life was considered unethical and inappropriate.Nurse, female, 60 – 62 years: “This man, at that time, he said clearly and unequivocally: "it is I who decide". Then the relatives persuaded him when we were not present. Therefore, I think there is a lot of hassle with family members.”Despite health personnel considering the treatment medically and ethically inappropriate, influence and pressure for antibiotic treatment from residents’ next of kin were described as a persistent barrier towards correct antibiotic use in NHs. Both the physicians and nurses expressed that diagnostic and antibiotic treatment should be based on residents’ wishes and medical decisions made by physicians. However, several informants from both professions were inclined to give in to non-coherent wishes and pressure from the next of kin. Lack of residents’ own voice, and cases where residents’ earlier wishes prior to the incapacity were unknown, were described as potential conflict-generating situations. Some nurses even described cases where residents clearly had expressed specific treatment wishes, but through persuasion by next of kin had chosen to change their position regarding treatment per the relatives’ wishes.Nurse, female, 60 – 64 years: “But the grandson of the resident, who himself was a doctor, would not give up. Therefore, we talked with our physician and expressed that this was not correct. Then we decided to prescribe antibiotics for two or three days and then discontinue the treatment.”Some of the nurses further expressed an impression that residents’ relatives over the years increasingly have gained power concerning diagnostic procedures and initiating antibiotic treatment.Nurse, female, 45-49 years: “Whom are we actually treating? Are we treating the resident or the relatives?”Disagreement between health care professionals and next of kin was widely discussed in several interviews as a common challenge concerning antibiotic treatment. Regarding frail elderly residents, the nurses and physicians described relatives who exhibit unrealistic expectations of the treatment effect of antibiotics and do not understand why diagnostic testing needs a clinical indication. Fear of negative coverage in the local newspaper or filing complaints to the municipality’s management department were reasons described for giving in to pressure from next of kin. Another reason for succumbing to the wishes of residents’ next of kin was the experience that this approach generated less work for the physician, as dealing with disagreements and conflicts were time-consuming and tiring. When exposed to strong disagreements regarding antibiotic treatment, some expressed that they simply chose to follow the wishes of next of kin to avoid conflicts. One physician explained that in cases where family members demanded antibiotic treatment in apparent unethical or medically futile situations, he often decided to treat with a narrow-spectrum antibiotic knowing that it would have no effect at all on the infection. Others described compromise-based approaches, which resulted in an antibiotic treatment attempt of two or three days, with subsequent termination of the treatment if the resident did not show signs of improvement.Nurse, female, 60 – 64 years: “The patient has a serious illness not yet diagnosed, which the hospital has chosen not to investigate any further. Therefore, if we do not talk openly about this the relatives might wonder why in the world we do not treat their dad, right?! Such cases need clarification.”Advance care plans, applying primarily for long-term-care NHs, were generally seen as valuable, reassuring and important by both physicians and nurses when dealing with new-onset infectious conditions, mainly concerning whether the resident should receive antibiotic treatment or not.Early stage dialogue with residents’ next of kin, often connected with advance care planning, was highlighted as facilitators for achieving ethically and medically correct antibiotic treatment of NH residents. Perceived benefits of early dialogue included building trust relationships, maturing and curbing relatives for future deteriorations in health and deciding level of antibiotic treatment prior to these events. Professional experience of healthcare workers, continuity in terms of full-time employment of physicians, and collaboration and agreement between health care professionals on complex issues regarding antibiotic treatment were described as important facilitators for trust building with next of kin. Although next of kin was generally described as needing repeated reality-oriented conversations concerning conflicting issues, such dialogues were considered an essential measure for ethically and medically correct antibiotic treatment.Physician, male, 40 – 44 years: “By being present every day, I think you get to use antibiotics in a much better way compared to arriving at a NH to attend an ill resident you do not know from before. Then it is much easier to think, “yes we’ll start antibiotic treatment because he is ill.”Both professions described the collaboration between nurses and physicians as non-problematic in terms of antibiotic treatment. Some physicians emphasized that due to the intervention, the collaboration worked better because the nurses to a lesser extent conducted point-of-care testing on their own initiative. Likewise, some physicians also highlighted decreased pressure from the nurses to initiate antibiotic treatment during and after the intervention, further adding to better collaboration between the two professions. Both professions pointed to the crucial role of nurses regarding the diagnostic process, where several of the physicians expressed that the nurses literally acted as their “eyes and ears” in many clinical decisions.Physician, female, 40 – 44 years: “We are very dependent on the nurses, it is therefore very important that they have a competent clinical view and that the collaboration works well.”Similarly, the nurses perceived their role in clinical decision-making processes as significant, and thus having a major impact on physicians’ clinical decisions. One physician pointed out that if a nurse wanted a resident treated with antibiotics, the nurse would have no problem convincing the physician into treating the resident.Physician, male, 35 - 39 years: “Yes, so it is how they (the nurses) describe it. They will get a cure for urinary tract infection if they want. They can report that the patient is more restless, has frequent urination and so on.”Some physicians and nurses described two potential barriers of appropriate antibiotic use regarding the nurse role. First, different nurses may have consistently different interpretations and reports of clinical observations. Secondly, nurses’ accuracy in relation to adherence regarding dosing intervals of oral antibiotics was described as often inaccurate, while with intravenous antibiotics the adherence to the intervals was usually accurate. Some of the nurses confirmed this, and described that one possible reason may be that residents treated with oral antibiotics are not considered as ill as those receiving intravenous antibiotics.Deficient staffing resources, especially concerning physicians, were described as an important barrier in terms of optimizing diagnostics and antibiotic treatment of residents. By having frequent access to the permanent NH physician, who inhabits knowledge of the residents and their medical history, this was perceived as a benefit for the residents themselves and facilitate both medically and ethically appropriate use of antibiotics.Nurse, female, 25 – 29 years: “We get patients referred with a plan, like an antibiotic regimen. But the real reason for admission is that relatives are going on holiday … they take a urine sample, find something on the dip stick and then they are admitted to us.”One issue that applied explicitly to MACUs was that the diagnosis given in referral letters from general practitioners (GPs) and emergency physicians (OOHS) often was perceived as deliberately incorrect. Several of the MACU nurses and one MACU physician expressed a suspicion that the referring physicians often used wrong referral diagnosis as a shell hide for the real reason for admittance. UTIs and dehydration were mentioned as frequently used diagnoses to justify admissions to MACUs, while the real reasons for referral often were perceived as pressure from the patient’s relatives or the home nurse service regarding inclining difficulties living at home due to age, cognitive impairment and frailty. Referrals to MACUs often include an antibiotic initiation plan when the admission diagnosis is an infection and is usually not re-evaluated until the MACU physician returns to the ward. Several of the MACU nurses looked upon this as a barrier of correct antibiotic treatment, as many of the referred UTI cases were actual cases of asymptomatic bacteriuria not requiring antibiotic treatment.Nurse, female, 35 – 39 years: “You call in an order, and you get what you ask for.”Regarding antibiotic treatment, several of the nurses and physicians in the interviews shared the opinion that OOHS physicians had a lower threshold for initiating broad-spectrum antibiotics. Lack of knowledge concerning resident history and lack of clinical examination of residents as the treatment decision often happens by telephone consultation were described as main barriers towards appropriate antibiotic use when initiated by the OOHSs.Physician, male, 30 – 39 years: “I think that the OOHS physicians do not know the residents very well, and to them an ill resident is an ill resident. They do not think about what kind of quality of life this patient already has. So they are faster to start treatment, and perhaps more broad-spectrum and more intravenous (treatment) than we might have done. Because they do not see the whole picture.”To avoid involving the OOHSs, some physicians pointed out they had agreements with their NHs to be available on phone outside working hours while others did not follow such practice as it resulted in too many inquiries after hours.The nurses generally expressed that OOHS was something they strived to avoid using as far as possible, as contacting the OOHS was tantamount to calling in a treatment order.Physician, female, 50-54 years: “When is enough, enough? One resident returned from the hospital with a gallbladder infection with intravenous antibiotics and nutrition, but the resident was over ninety years old with severe heart failure. Then you feel trapped with how long are you going to hold on, when are you supposed to stop the treatment? I felt the hospital over-treated the resident.”In general, the physicians described that they seldom challenged or re-evaluated hospital-initiated treatment, even in cases where antibiotic treatment clearly was questionable. Only if antibiotic treatments were excess broad-spectrum, further degraded residents’ quality of life or were obviously medically futile, some physicians expressed that they might contact hospital colleagues to discuss the treatment. Perceived barriers to challenging hospital-initiated treatments included respecting hospital physicians being specialists, better diagnostic possibilities at the hospital and difficulties defending change of treatment towards residents’ next of kin.Physician, female, 40 – 44 years: “Yes, so I know a little about a lot, they know a lot about less. It is natural that they should be better than me at this I think. If I am very stunned, I call to ask of course. However, to change (the treatment)? Then it has to be completely outrageous.”Several of the physicians and nurses shared thoughts and frustration regarding overtreatment of NH residents initiated during hospital stays. Palliative care and other residents with short life expectancy and reduced quality of life returning to the NHs with ongoing antibiotic treatment that clearly would outlive the resident itself, were perceived as particular problematic cases.We identified four overarching levels covering thirteen themes affecting the appropriateness of antibiotic use in primary care institutions: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level (Fig. Corresponding well with a previous Dutch study , we founLack of on-site diagnostic tools and resources was perceived as a persistent barrier in achieving medically optimal antibiotic treatment and has previously been described , 34. Theet.al. where the patients’ individual preferences seemed to have a more peripheral role in the decision-making regarding life-prolonging treatment [Awareness and emphasis on patient autonomy and consent-competence were described as important facilitators for ethically and medically appropriate antibiotic prescribing. The informants shared the opinion that consent-competent residents, able to express treatment desires, should be the major guiding factor in treatment decision-making. This finding somewhat contradicts the findings of Klomstad reatment . In contreatment , 50.Antibiotic therapy in palliative medicine is an area permeated by ethical issues without a single correct answer. Although most informants shared the agreement that one should avoid antibiotic treatment in residents with obvious short life expectancies, some informants expressed willingness to treat palliative care residents with antibiotics to relieve discomfort associated with infections. This tendency corresponds well with the findings of a recent North American descriptive survey, where most participating NHs reported that end-of-life residents likely would receive antibiotics if UTI was suspected . TherefoThe nurses frequently described next of kin’s expectations as one of the most considerable barriers towards achieving medically and ethically appropriate antibiotic treatment. The decision-making influence from next of kin is well known from previous NH studies , 53. AntHowever, situations presenting contradictions between treatment decisions and one’s own work ethic and known good clinical practice may not be mitigated by advance care plans, dialogue with next of kin, increased clinical knowledge and collegial conferring alone. Increasing the professional knowledge and experience of care givers in the field of ethical issues in NHs through education, guidelines and ethical reflection groups, may contribute to health personnel becoming more robust in the face of such challenging situations. During the opening conference of the intervention, a professional presentation alongside a workshop covering ethical aspects of antibiotic treatment in NH residents were held in this regard. Although not mentioned by the informants during the interviews, in demanding ethical cases where the above components fall short as to solve the issue, a clinical ethics committee may be contacted for advice and guidance in specific cases. All major health trusts in Norway and some municipalities have a clinical ethics committee which may be contacted by NHs when needed.Lack of permanent physicians and infrequent regular medical visits is a common everyday situation, especially for small NHs in Norway  and abroOur findings regarding the influence of nurses in the diagnosis and treatment of infections are by no means unique , 33, 34.et.al [MACUs are a relatively new service in the Norwegian health service, and research in the field is so far scarce. In the current study, the informants expressed a suspicion that several of the referral diagnoses stated by GPs and OOHS physicians are used as cover for other conditions or situations less suitable for admittance to MACU wards. By exploiting the large incidence of asymptomatic bacteriuria in the elderly as a gateway to MACUs, this increases the risk of unnecessary antibiotic prescribing. Cumbersome and defiant collaboration between MACU employees and GPs regarding admittance to MACU’s, as well as vague admission criteria as perceived by GPs, have previously been described by Johannessen et.al . Togethe, which describe communication failure at all stages of the patient pathway in the collaboration between NHs and hospitals [Previous Norwegian studies have shown that hospital-initiated antibiotic treatment in some instances should be challenged, including the spectrum of the initiated antibiotic treatment and the outlined treatment duration , 57. Desospitals , this arThe main strength of the study is the investigation of not only physicians’ perspectives, but also perspectives of NH nurses given their obviously significant role in the antibiotic decision-making. Furthermore, the informants’ wide range in age and working experience resulted in rich and varied feedback that broadly and realistically embraces the everyday clinical life in Norwegian primary care institutions.As a limitation applicable to most qualitative research, this study cannot firmly conclude to what extent each identified barrier and facilitator affects antibiotic prescribing in NHs and MACUs. In order to present precise assumptions around the magnitude of each factor, future observational and quantitative studies are warranted. Another possible limitation of the study may be the composition of informants in the first four interviews, in which both physicians and nurses participated together. This may have resulted in some informants being reluctant to express themselves credibly and truthfully about their own role and concerning the other occupational group present during the interviews. Based on this potential limitation, we conducted the two last interviews with only physicians present in one and only nurses in the other one, without observing any apparent differences in the feedback or dynamics compared to the first four interviews. We therefore believe that if such impact has found place during the mixed interviews, it has been of minor relevance to the results of the study. There might have appeared changes in the investigated field in 4 years’ time between data collection and publication of the results. However, we have not identified any new relevant guidelines or published literature from Norwegian NHs addressing the area of interest in the time period between data collection and publication. We, therefore, believe our results and conclusions stands viable and firmly and adds valuable knowledge to a field where prior research is scarce. Lastly, when interpreting the results of the study, it is important to remember that our findings are based on descriptions and perceptions of the physicians and nurses, and thus lacking the views and experiences of residents, next of kin, other health care professionals from other health services and the management representatives from the institutions.After the completion of a one-year antibiotic quality improvement intervention, our focus group study reveals a wide variety of persistent barriers influencing antibiotic prescribing in the participating NHs and MACUs. Unclear clinical presentation of symptoms, lack of diagnostic possibilities and pressure from next of kin were perceived as major barriers to appropriate antibiotic use. On the other hand, increased knowledge and awareness, appropriate use of point-of-care tests, increased availability of permanent NH physicians and early and frequent dialogue with the residents’ next of kin were important facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process was by both professions described as profound. We encourage targeting these factors in future antibiotic stewardship programs to achieve the most adequate antibiotic treatment possible. Future studies should lean towards quantitative and observational methods to gain more knowledge of how to overcome barriers and contribute to practice- and implementation developments to ensure optimal antibiotic prescribing to elderly patients.


Prosthetic joint infection (PJI) is a severe complication after arthroplasty. Its management combines surgical intervention, whose type depends on the clinical situation, and prolonged high-dose antibiotics adapted to the responsible microorganism(s) and the patient. Antibiotics are only one part of the therapeutic regimen and are closely related to the surgical strategy. Their efficacy depends to a large extent on the choice and quality of the surgical procedure, and the quality of the microbiological diagnosis. Although guidelines have been published, many aspects of antibiotic therapy remain poorly established. Choosing the optimal agent(s) is one aspect, with others being optimization of drugs’ pharmacokinetic/pharmacodynamic parameters, the choice of administration route, use of monotherapy or combination regimens, therapeutic drug-monitoring and patient education to improve compliance and tolerance. Herein, we address PJI management based on recent literature data, guidelines and the experience of our referral center for complex bone-and-joint infections. Joint arthroplasty is now a very common and successful surgical procedure to restore joint function. Nearly 200,000 total hip replacements are performed annually in France. It is estimated that, by 2050, this number will increase 42–112.3% [PJI treatment is complex because it deals with a large number of different clinical contexts, relying on specific surgical and medical strategies, which have to be adapted to the patient. A multidisciplinary approach, with strong collaboration among all medical and surgical personnel involved, is essential. Antibiotics represent only a part of PJI management and are closely linked to the surgical strategy applied. Their efficacy is highly dependent on the choice and quality of the surgical procedure, and on the quality of the microbiological diagnosis. International guidelines were published nearly 10 years ago . As streClinical diagnosis of PJIs can be challenging because of the indolent course of chronic infections, difficulties culturing low-virulence bacteria, and the wide variety of microorganisms and antibiotic-resistant phenotypes that can be involved ,7. PreciOptimal curative treatment of PJI combines surgery and prolonged, high-dose, antibiotic therapy. Two very different surgical strategies are applied, depending on the clinical picture: prosthesis retention with débridement, synovectomy and exchange of the mobile elements for acute infection, while biofilm formation is still ongoing; or prosthesis removal followed by a new arthroplasty during one- or two-stage exchange for chronic infections.PJI treatment requires optimal antibiotic coverage, especially during the early phase, i.e., the first postoperative weeks. Although the bacterial load is reduced by surgery, high-dose antibiotics and optimization of PK/PD parameters achieve better infection control  and loweTo optimize the efficacy of time-dependent antibiotics, such as β-lactams, vancomycin and clindamycin, whose activities are linked to the time during which their concentrations exceed the pathogen’s minimal inhibitory concentration(s) (MIC(s)), continuous or extended IV infusion is appropriate.The results of a recent, prospective, comparative study on continuous or 3 h vs. intermittent cloxacillin infusion showed >90% probability of target attainment, i.e., 100% of the time at a MIC < 0.5 mg/L, for the continuous-infusion group .We reported the feasibility, efficacy and safety of continuous cefazolin, clindamycin, vancomycin or ceftazidime ,14,15,16min 0.37 mg/L) were very low, dramatically below the target concentration [In a recent, prospective PK study on the influence of the administration route on the magnitude of clindamycin–rifampicin interaction, we also showed that continuous clindamycin infusion reached therapeutic plasma concentrations (3–8 mg/L), even combined with rifampicin, a strong inducer of hepatic enzymes, thereby significantly decreasing plasma clindamycin concentrations . When contration .The use of continuous meropenem administration was evaluated in some trials, whose results indicated improved PK efficacy ,19, bettContinuous IV infusion requires an initial antibiotic-loading dose, started at the same time as the continuous infusion, to rapidly attain the target plasma concentration. Moreover, adequate preparation  and antibiotic administration  by experienced teams, during hospitalization and outpatient therapy, are essential to assure drug stability and antibacterial activity .Little is known about the bone antibiotic concentration obtained after continuous antibiotic infusion. In our cohort study on 100 patients treated with continuous IV cefazolin infusion, the determinations of eight patients’ bone cefazolin concentrations revealed broad variability and a median bone/plasma ratio of 25% .How long the initial IV regimen should be administered remains controversial. The trend is to shorten IV therapy to avoid catheter-related complications, shorten the hospital stay, lower related costs and improve patient comfort .The British randomized-controlled Oral Versus IntraVenous-Antibiotic (OVIVA) trial compared patients treated for nonsevere BJIs with 6 vs. 1 week of IV antibiotics, then continued orally. The study population consisted of a variety of BJIs , with and without foreign material, which were treated with either implant retention or removal. After 1 year of follow-up, no difference between the two groups was observed in terms of treatment failures, 14.6% vs. 13.2%, respectively . AuthorsSeveral factors have to be taken carefully into consideration to determine when treatment can be continued orally . First, For patients with difficult-to-treat or resistant bacteria, complex surgeries including extensive bone reconstruction and/or gastrointestinal intolerance or malabsorption, IV antibiotic administration will be prolonged or even maintained for the entire treatment duration. After hospital discharge, treatment can be administered IV by either OPAT services or experienced rehabilitation teams.Poor treatment adherence and self-medication are two of the most important problems of antibiotic misuse. Adherence has been specifically studied in chronic but not acute diseases, such as infectious diseases. A meta-analysis found that 38% of patients forget to take at least 1 antibiotic dose . Recent Prolonged antibiotic use is required. Administration duration remains controversial and ranges between 6 and 12 weeks, according to the medical–surgical strategy  and teams. Duration is longer for DAIR strategies and reportedly can be <2 weeks after two-stage arthroplasty .Very few randomized trials have explored that situation. Most included small numbers of patients. Different surgical strategies were applied. According to a Spanish study that included 63 patients with acute staphylococcal PJIs managed with DAIR and combination levofloxacin–rifampicin found that 8 weeks of antibiotics was not inferior to 3–6 months . A SwissS. aureus PJIs require longer treatment than very susceptible streptococcal or enterobacterial infections. Future randomized trials on these different and specific situations are needed to further clarify treatment duration.Taken together, many questions concerning antibiotic duration for PJIs persist; it has to be adapted to the surgical strategy. Recent data underline the importance of longer treatment for prosthesis retention. We recommend treating acute DAIR-managed PJIs for 12 weeks, if the regimen is well tolerated. Chronic PJIs with prosthesis removal managed with one- or two-stage exchange arthroplasty, exceptionally with resection arthroplasty, can be treated for 6 weeks postoperatively. For cases at high risk of relapse, e.g., patients receiving chemotherapy or taking immunosuppressants, with CHILD B or C cirrhosis, PJI involving irradiated bone or extensive osteomyelitis or requiring large bone grafts, or patients with relapsing PJI previously having been treated with exchange arthroplasty, more prolonged treatment lasting 12 weeks should be considered . The typPJI pathophysiology is characterized by biofilm formation, a universal and major bacterial survival mode in which bacteria form a microbe-derived sessile community attached to a surface. Biofilm is composed of an 80% polysaccharide layer  in which the bacteria are embedded. They adhere irreversibly to the prosthesis, slow their metabolism, multiply little and their growth rate and gene-transcription phenotypes are modified. Biofilm formation protects them from the host’s cellular response thereby enabling antibiotic resistance and tolerance . TreatmeRifampicin antibacterial activity against staphylococcal infections in animal models is concentration-dependent, with the area under the time–concentration curve (AUC)/MIC and peak concentration/MIC ratios being predictive of its activity . The druThe optimal rifampin dose remains a matter of debate. Recommendations and practices vary according to country and team. Authors of a recent, retrospective, single-center study on 411 patients with acute or chronic staphylococcal PJIs treated with various strategies  found that rifampicin doses <10 mg/kg/day were not less effective than higher doses (10–20 mg/kg/day and >20 mg/kg/day) . HoweverRifampicin has complex PK properties. Its intestinal absorption varies with food intake. It is metabolized in the intestinal tract and the liver. It is a major cytochrome P450 and intestinal transporter inducer, responsible for important drug interactions, and even induces its own transformation and elimination. Marked interindividual AUC and plasma-concentration variations have been observed ,45. The Taking into account all these drug characteristics and fragility, we recommend avoiding low doses, giving a 600 mg unit dose, twice a day, except for very underweight (<50 kg) or overweight (>90 kg) patients, for whom the dose must be adapted. Studies and recommendations on tuberculous treatment underscored that the higher rifampicin dose obtained better efficacy with no additional toxicity . If avaiGastrointestinal AEs are frequent (20–30%), especially during the first week of treatment. Initial IV administration can help avoid drug underexposure during the early postoperative phase. In their prospective observational study on 46 patients treated for BJIs, Roblot et al.  found noOther drugs, such as linezolid, daptomycin and vancomycin, also have antibiofilm antibacterial activity in vitro . To dateAntibiotic bone diffusion is another important parameter of PJI treatment, especially for chronic infections with bone involvement. The bone/plasma ratio has been reported in several publications ,49,50,51Finally, bone penetration is one among other factors to consider when choosing antibiotics to treat PJIs. MIC of the involved microorganism, the drug’s PK/PD properties, activity on biofilm-embedded microorganisms, drug toxicity and clinical study results are other major parameters that guide treatment choice.These difficult-to-treat PJIs require prolonged high-dose antibiotic administration. They often develop in old and/or obese patients with multiple comorbidities and polypharmacy use, which can modify drug PKs. During the postoperative phase, several metabolic disturbances can occur . Drug AEs are also frequent. Multiresistant microorganisms can be involved, thereby limiting available therapeutic options. For all these reasons, antibiotic optimization and adjustment to each patient’s characteristics, underlying conditions and drug tolerance, and microorganism susceptibility, are fundamental. Determination of plasma drug concentrations, more commonly known as TDM, is one of the ways to optimize antibiotic use, along with MIC determination and high-dose prolonged or continuous infusion with time-dependent antibiotics.Vancomycin has a low therapeutic index. In our experience, continuous, IV, high-dose vancomycin combination therapy is effective against methicillin-resistant staphylococcal PJIs. TDM is necessary throughout treatment to limit nephrotoxicity observed in one-third of the patients .Pseudomonas aeruginosa BJIs [Beta-lactams have a large therapeutic index, usually not indicating TDM. However, in complex situations involving multiresistant or difficult-to-treat microorganisms, in multioperated and/or relapsing-PJI patients or those with renal insufficiency or obesity, TDM helps optimize drug administration by limiting over- and underdosing, and reach target concentrations. In a prospective comparative study on 52 patients, Gomez-Junyent et al. compared the outcomes of fluoroquinolone-resistant and susceptible osa BJIs . Prolongosa BJIs . The dososa BJIs ,16,56 prAntibiotic concentration measurements can also reveal or confirm drug interactions. Based on a large retrospective cohort study on 70 BJI patients treated with continuous IV clindamycin combined with rifampicin or without, we previously described a 40% rifampicin-induced decrease in the median plasma clindamycin concentration . More reNo data on TDM of fluoroquinolones in patients with BJIs have been published, but fluoroquinolone TDM is used to optimize treatment of multiresistant tuberculosis . High inTo conclude, TDM helps optimize antibiotic therapy, especially in complex microbiological or PK settings. However, it is only an evaluation of the bone antibiotic concentration and not an assessment of antibiotic activity; it is, nonetheless, an important parameter for an individual therapeutic approach. Large studies are needed to confirm that TDM improves PJI treatment efficacy and tolerance.Empirical antibiotic therapy, usually combining a broad-spectrum β-lactam with good activity against Gram-negative rods, such as piperacillin–tazobactam or –cefepime, and a drug effective against Gram-positive cocci, including methicillin-resistant staphylococci, such as daptomycin or vancomycin, is often—and certainly too often—used at treatment onset, while waiting for the results of intraoperative sample cultures. Different clinical contexts should be distinguished to better discern the indication of such broad-spectrum therapy, which is expensive, markedly impacts human-flora ecology and leads to drug-related toxicity . ThorougFor early postoperative PJIs, the wide range of microorganisms that can be involved, a high polymicrobial infection rate and urgent surgery, warrants the use of such a broad-spectrum regimen ,59.On the contrary, acute hematogenous PJIs are almost always (99%) monomicrobial. MSSA and streptococcal infections are by far the most frequent pathogens isolated. Cefazolin or cloxacillin is the first-line antibiotic in this context. Third-generation cephalosporins are recommended when Gram-negative rods are suspected. Search for an infection source is an additional step to orient treatment choice .Staphylococcus epidermidis, but also anaerobic bacteria, for example, Cutibacterium acnes [Finally, for late chronic PJIs, urgent surgical intervention is not needed. Management starts with confirming PJI and isolating the involved microorganism(s). In our experience, the choice of the initial antibiotic regimen is guided by those microbiological results and previous intraoperative sample cultures, if the patient has been managed in another center. The initial treatment also depends on the number of previous same-site operations and the surgical strategy applied . This type of PJI often harbors low-virulence microbes, such as coagulase-negative staphylococci (CNS), with a high rate of methicillin-resistant um acnes . Broad-sFor critically ill patients, appropriate broad-spectrum antibiotic therapy is usually initiated rapidly, in combination with an aminoglycoside to enhance the antibacterial activity, unless the patient has developed severe renal insufficiency.Once microbiological results become available, it is essential to tailor the antibiotic regimen from empirical coverage to pathogen-specific treatment .Clinical practice guidelines from different countries, published during the last 10 years ,60,61, hS. aureus and S. epidermidis being the most frequent species [Staphylococci are by far the most common microorganisms isolated from PJIs, with  species .Numerous authors observed and analyzed the outcomes of DAIR-treated MSSA PJIs treated with prosthesis retention. The treatment of choice for methicillin-susceptible staphylococcal PJIs is initial IV antistaphylococcal β-lactam, oxacillin or cefazolin ,25,60. PS. aureus PJIs [In a retrospective comparative cohort study, Vollmer et al. analyzed the safety and tolerability of fluoroquinolones in 156 patients with DAIR-treated eus PJIs . The unpeus PJIs  insistedWhen rifampicin use is not possible, alternative treatments are oral regimens combining levofloxacin with clindamycin, minocycline or co–trimoxazole. Monotherapy with those drugs has not yet been validated. However, Infectious Diseases Society of America guidelines recommend cefazolin or oxacillin IV monotherapy for the entire treatment duration .Alternative nonfluoroquinolone regimens are IV rifampicin–clindamycin or –cefazolin with good efficacy and tolerance based on our large, retrospective cohort studies ,14. OralS. aureus (MRSA) and CNS, data from randomized trials or large cohort studies are lacking. International guidelines recommend vancomycin as the preferred agent [S. epidermidis strains than S. aureus [Concerning methicillin-resistant ed agent ; daptomyed agent . Methici. aureus ,8,72. An. aureus .To optimize vancomycin therapy, continuous IV, high-dose vancomycin-combination therapy is the preferred modality . Plasma Daptomycin is a valuable alternative option to treat methicillin-resistant PJIs and has less drug-related toxicity. Reported cure rates range between 54% and 87.5% ,76,77. SLinezolid is an option, when neither vancomycin nor daptomycin can be used. Despite its high bioavailability and in vitro efficacy against methicillin-resistant staphylococci , linezolDalbavancin has been prescribed to treat staphylococcal PJIs, but very small numbers of patients were enrolled in those studies and methicillin-susceptible strains were often included. Overall clinical cure rate was 73% .S. aureus hip and knee PJIs in their systematic review and meta-analysis  [Sheper et al. observed better outcomes of DAIR-treated CNS vs. ctively) .S. aureus. The majority of Streptococcus spp. that cause PJIs include group-B streptococci  and viridans-group streptococci [S. aureus, but the question remains whether or not streptococcal PJI outcomes are better than staphylococcal infections. The results of a large study showed poor outcomes for DAIR-treated Streptococcus spp. PJIs [S. agalactiae and DAIR as factors associated with failure [Although staphylococci are the predominant pathogens isolated from PJIs, streptococci are the second most common microorganisms, found in 9–16% . Streptoptococci . Streptopp. PJIs . Another failure .β-Lactams are the first-choice treatment for streptococcal PJIs, except for penicillin-allergic patients. In their very large retrospective study on DAIR-treated streptococcal PJIs, Lora-Tamayo et al. observed that prolonged (≥21 days) β-lactam therapy was associated with therapeutic success. International guidelines recommend initial IV therapy with high-dose penicillin or ceftriaxone. Amoxicillin is also often given and is the first-choice treatment recommended by the French guidelines . InitialCombination therapy with rifampicin remains controversial. Some authors use and recommend combination therapy with levofloxacin and rifampicin . AccordiFor penicillin-allergic patients, cefazolin, ceftriaxone, clindamycin, vancomycin or daptomycin are valid options for the initial IV therapy. Clindamycin rather than levofloxacin can be used for oral therapy, if the strain is susceptible. Linezolid should be reserved for when the other options are contraindicated.For hematogenously spreading infections, identification and treatment of the infection source contributes to avoiding recurrent PJIs.Enterococcus spp. are less susceptible to penicillin than Streptococcus spp. Enterococcal PJIs have been associated with treatment failures and recurrent infections [fections . Polymicfections ,93. Therfections ,95.Optimal treatment of these difficult-to-treat infections still has to be defined. International guidelines recommend high-dose IV penicillin or ampicillin. Combination therapy with gentamicin remains the prescriber’s choice . In our Enterococcus spp. or penicillin-allergic patients, IV high-dose vancomycin or daptomycin can be used. The oral regimen is limited to linezolid or the less toxic oxazolidinone, tedizolid.For resistant Dalbavancin was administered every 2 weeks for 2–3 months to 16 patients with Gram-positive PJIs, including six enterococcal infections; none of those patients relapsed . Larger P. aeruginosa PJIs is considered difficult because of the bacterium’s natural resistance to many antimicrobials, increasing acquired resistance, the nosocomial environment and patients’ comorbidities [P. aeruginosa PJIs are not well defined, and several questions remain. Agents with good activity against P. aeruginosa include ceftazidime, cefepime, piperacillin–tazobactam and carbapenem. Ciprofloxacin is the only available oral treatment for P. aeruginosa. Amikacin and tobramycin have intense bactericidal activity against P. aeruginosa.Treatment of bidities ,7,99. ThP. aeruginosa BJIs [P. aeruginosa infections, among which 30 were PJIs [P. aeruginosa PJI cohort [n = 32), chronic, ciprofloxacin-susceptible infections (n = 35) and were treated with one-stage exchange (n = 27) and prolonged IV antibiotics. Overall, 82% percent of the patients and 93% of those managed with one-stage exchange had favorable outcomes.Only a few retrospective studies focused on osa BJIs . Recentlere PJIs . Better I cohort . Most weInternational guidelines place cefepime or meropenem as the preferred agent, with ciprofloxacin and ceftazidime as alternatives. Adding aminoglycoside is treating physician’s choice; it can also be used locally in a spacer. Cefepime achieves high bone diffusion according to data from only one study .P. aeruginosa [Taking all these results together, prolonged (≥21 days) β-lactam combined with ciprofloxacin is certainly the treatment-of-choice for susceptible strains. In our recently reported experience, ceftazidime was the first-choice β-lactam, because of its excellent bactericidal activity against ruginosa . CefepimP. aeruginosa PJIs, high-dose IV therapy is needed throughout the treatment duration. The potential benefit of combination therapy with other drugs  has to be evaluated. Meropenem alone or in combination with other active drugs or ceftazidime–avibactam can be to treat multiresistant strain PJIs.Although no standard treatment is recommended for ciprofloxacin-resistant Enterobacteriaceae account for about 11–22% of PJIs ,103. TheInternational guidelines for treating Enterobacteriaceae PJIs  recommenThe prevalence of multidrug-resistant Enterobacteriaceae has been increasing for >20 years because of the broad variety of β-lactamases . Many ofCutibacterium spp. are highly susceptible to a wide range of antibiotics: ¦beta-lactams, clindamycin, rifampin, vancomycin and daptomycin [Cutibacterium is naturally resistant to metronidazole. Currently available clinical data on these anaerobic opportunistic agents have not enabled definition of the optimal antibiotic therapy and no antibiotic-therapy consensus exists for Cutibacterium infections. Therapeutic regimens vary widely among countries and institutions. American guidelines [Cutibacterium acnes grows in biofilm and usually causes late, chronic PJIs, especially after shoulder arthroplasty [Staphylococcus was isolated, because of the lack of proven benefit of combination therapy and frequent AEs.ptomycin ,108. Howidelines  recommenidelines  recommenroplasty ,111. Theroplasty ,113,114,roplasty , ceftriaroplasty  when no Cutibacterium avidum PJIs, we observed clindamycin-resistance in one-third and isolation of CNS or other anaerobes was also not rare [C. avidum PJIs, while waiting for the final culture results of intraoperative samples.In patients with not rare . For theCorynebacterium spp. PJIs are rare, around 1–2% [Corynebacterium striatum is the most frequently isolated species [Corynebacterium striatum is almost always penicillin-resistant [C. striatum PJIs treated with various strategies [und 1–2% ,8, as arund 1–2% ,118. Cor species ,119. The species . Amoxiciesistant . Noussairategies .Mycoplasma hominis, among others) or a microbe requiring special culture media, e.g., mycobacteria or fungi. A relatively recent literature review of the epidemiology, diagnosis and treatment of culture-negative PJIs emphasized that the definitive diagnostic method for identifying causative microorganism(s) has not yet been clearly described [Culture-negative PJIs, ranging from 0% to >40%, represent an important and challenging issue for teams managing PJIs. The first step consists in establishing whether the cultures are truly negative and if the patient has a diagnosis other than a prosthesis infection. A false-negative may be attributable to prior antibiotic therapy, difficult-to-culture microorganism  and treatment strategy. In our cohort of 157 chronic PJIs treated with one-stage exchange arthroplasty, median preoperative therapy lasted 7 (IQR 4–11) days [S. agalactiae PJIs, based on joint aspiration-culture results [Preoperative antibiotics are usually not administered so as to assure the sampling of valid intraoperative samples for cultures. When the etiological diagnosis has been established by preoperative joint aspiration, especially for infections caused by idelines  recommen11) days . Accordi results .Prolonged suppressive antibiotic(s) with an oral regimen may be warranted for patients with progressive infection who are unsuitable for a curative procedure or refuse surgery. It is also a valid option for some patients with multiple recurrent PJIs . This meS. aureus and P. aeruginosa PJIs with a good clinical response [Future strategies for PJI management include phage therapy. It is still the exception, but intra-articular administration of selected bacteriophages has been combined with salvage DAIR surgery in patients with recurrent response ,134. HowOther local approaches attempt to improve the antimicrobial properties of inert Titanium orthopedic devices by using a multifunctional antimicrobial coating, also called biofunctionalized prosthesis. They combine passive antibacterial coating of the surface to prevent initial attachment of bacteria and an active antibacterial and immunomodulatory agent coating, which is released in the environment to improve the local immune and antimicrobial response . ClinicaPJIs regroup various entities that differ by their postoperative or hematogenous contamination route, acute or chronic evolution, responsible microorganism(s) and their antibiotic susceptibilities, infection site and patient profiles. Choosing the optimal antibiotic regimen for a given patient must take all those parameters into consideration, together with the surgical strategy applied. Alternative regimens to the first-choice therapy are needed in case of adverse events or contraindication to certain drugs. The regimen for DAIR-treated MSSA PJIs is well codified. In contrast, many questions persist concerning the choice of antibiotics to treat PJIs caused by other pathogens. To address those unresolved issues, future studies should be designed to target well-defined settings, i.e., type of infection, microbe(s) and surgical strategy.


High-strength concrete is designed for a self-weight reduction structure and exhibits higher resistance to compressive loads. This paper proposes a novel technique to enhance concrete’s properties using Magnetic Field Treated Water (MFTW), describing the results of experimental studies to apprehend the fresh, hardened and microstructural behavior of concrete prepared with Magnetic Water (MW) using a permanent magnet with a field intensity of 0.9 Tesla. The novel scheme focuses on utilizing MW as a water-reducing agent instead of SP to improve the workability of fresh concrete with a 0.38 w/c ratio for achieving M40 grade concrete. Results show a 12% improvement in compressive strength and an 8.9% improvement in split tensile strength compared to normal water (NW) with 1% SP. At 30% cement volume reduction, Magnetic Water Concrete (MWC) performs better than Normal Water Concrete (NWC). Microstructure examination shows that a smaller Calcium Hydrate (CH) crystal is formed with MW and its mineral composition is observed through Energy Dispersive X-ray Analysis (EDAX). Water quality and quantity play a crucial part in the strength attainment of fresh and hardened properties of concrete. Concrete technologists are becoming more interested in Magnetic Water’s (MW’s) potential use in mixing concrete to enhance the concrete’s quality. In MW, water is passed through the magnetic field to become magnetized. As a result, the negative ionic hydration is increased, and potentially harmful water crystal structure is found [Nowadays, most metropolitan cities in India have domestic water shortage problems due to the lack of monsoon rains and depleted groundwater tables. Currently, the construction industry uses an enormous quantity of potable water for several purposes. Of especial concern in this paper, nearly 150–200 L of fresh water are consumed to produce 1 mis found . It has is found . The infis found . In exceis found . It is eis found . In addiis found .Research has mainly focused on reducing water admixtures with super plasticizers (SPs) to achieve high workability while producing high-strength concrete . An incrThe porosity and water absorption sorptivity are higher in MW passing through the magnetic intensity of 0.8 T and 0.9 T, but less with 1 T . MeasureThis paper focuses on studying high-strength concrete’s fresh and hardened properties using MW as a water-reducing agent instead of SP. Here, the water is magnetized through PERMAG (N407) with a field intensity of 0.9 T, and the fresh concrete specimens were prepared by varying SP dosage (from 0 to 1% by volume of cement). Moreover, the effect of MW with different exposure times and storage time on fresh concrete properties is optimized. In addition, granite wastage was also examined as a partial replacement for cement volume with different substitution levels mixed with MW. This research also included microstructural and energy dispersion studies on concrete samples to evaluate the hydration rate of C-S-H crystal and element identification while mixed with NW and MW. The main contributions of this paper are to examine the effect of fresh and hardened concrete properties of high-strength concrete using MW without the addition of SP, and to incorporate granite waste as a filler material for cement with an equal interval of addition mixed with MW. The proposed approach will help improve water quality in the concrete industry due to the water magnetization, which directly enhances the quality and durability of the structures.3. This cement has many physical properties, such as fineness, initial and final setting time, consistency, specific gravity and chemical composition, and the test values are shown in Portland cement (Type I) has been used in this study, with a specific density of 3.10 g/cm2/gm and the particle size distribution of cement [The specific surface area of cement is 3268 cmf cement  is displThe physical properties of fine and coarse aggregate with 20 mm sizes are depicted in The chemical parameters of normal water after magnetization get changed and its quality is improved . The che3 of concrete. In our research work we have casted 87 specimens in total. To study fresh concrete properties we have casted 30 different concrete mixes , while for hardened concrete properties we casted 57 concrete specimens.2/g, respectively, which is the same as the fineness of the cement. Characterization of granite waste was performed using an X-ray Diffraction (XRD) technique.The granite waste used as a replacement for cement volume is obtained from the locally available granite processing industry in Salem, India. The specific gravity and fineness of granite waste are about 2.58 and 2.61 mThe experiment starts with a mixed proportion of M40 grade concrete with a water-cement ratio of 0.38, shown in To obtain the desired workability, the SP has been used as water reducing admixture and its dosage has been optimized by conducting the Marsh cone test. Then, the performance was evaluated through a slump cone test and slump resting time (NW with optimized 1% SP and MW without SP) by varying magnetic exposure time from 0 to 60 min with 15 min intervals. Fresh properties of M40 grade concrete were measured by conducting three tests: slump cone, Vee-bee and compaction factor (NW with optimized 1% SP and MW without SP) at different storage periods, i.e., 0, 15 and 30 min. Hardened concrete properties, such as compressive strength at 3, 7, 14, 21 and 28 days and split tensile strength, were measured at 7, 14 and 28 days of concrete from casting. The concrete cubes were prepared with MW by replacing cement volume by 30% with granite powder. The mineralogical studies of the granite waste were performed using XRD. Microstructure characterization of concrete samples (NW with optimized SP and MW without SP) were examined after 28 days of the curing period through SEM and EDAX.The Marsh cone test was conducted to optimize the SP dosage to achieve cement’s flow ability with a 0.38 water-cement ratio and varying percentage of SP from 0 to 1.4% with an increment of 0.2%. The saturation point was obtained by observing the time taken to collect 500 mL of cement paste passing from the nozzle of the Marsh cone. The test was conducted as per ASTM D6910 .The slump cone test is a standard method used to evaluate concrete mix consistency as per IS: 1199:1959 (2004) . The worThe fresh concrete may lose its workability with respect to time, known as slump loss. The retention time of slump depends on the factors like types and combinations of concrete materials used, ambient conditions, and the total quantity of utilized water . The sluThe compaction factor test was performed for concrete, which has low workability. The setup consists of an upper, lower hopper and cylinder. The test was performed as per IS: 1199: 1959 . The conVee bee is used to find the consistency and mobility of recently mixed concrete using a Vee-bee consistometer, and it was performed as per IS: 1199:1959 (2004) . The samThe compressive strength of concrete cubes has been evaluated as per IS: 516:1959 . Two setThe cylindrical specimen was prepared with 150 mm diameter and 300 mm height, and the NWC and MWC concrete were tested for tensile strength as per 516:1959 . After 3Concrete is highly heterogeneous and has a complex microstructure, and it consists of three components, i.e., hydrated cement paste, aggregate and interfacial transitions zone between the cement pastes and aggregate. The NWC and MWC samples of M40 grade concrete were characterized by SEM of model XL30 equipped with an EDAX spectrometer for X-ray dispersion element analysis, and micrographs images were taken from the surface of cement paste specimen .The chemical composition of of the granite powder waste is about 73% Silica (concrete . The minIt has been observed that granite waste contains more intense peaks of Quartz (PCPDF no.: 89-8935), Albite ite rock . The conite rock . Even thite rock . Since nThe Marsh cone test was conducted to optimize the uses of SP and compatibility between cement and SP to attain the required flow ability of concrete. The time taken to collect 500 mL cement paste was measured. It can be observed from The slump flow test is a frequently used method to evaluate the fresh concrete mix workability. Due to magnetization, the field produces a dispersion effect on water clusters due to magnetization and separates them into minor groups. Consequently, water molecules can readily pass through cement particles, where they can react with other cement particles. Thus, the magnetic field enhances the role of water in concrete, such as cement hydration and better flow ability . Hence, It can be noticed from Slump loss in fresh concrete is distinct from the loss of consistency in the concrete mix with respect to resting time. The results indicate that the slump loss of concrete prepared with MWC with respect to retention time indicates a similar trend to that of the NWC made with 1% SP. This implies that when long-standing resting is involved, MW acts as a super lubricant and impacts the electrical load of the cement particles that cause the separation of charges from each other. Thus, the MW easily penetrates the core region of cement particles and facilitates better lubrication for a longer resting duration . Hence, In The slump value is increased due to electrically charged water molecules due to magnetization, which improves the water interaction among cement contents on fresh concrete. It can also be noted that the magnetization effect is reduced with storage time once it leaves the magnetic field .The compacting factor test was performed to measure the workability of concrete when the slump value is less than 50 mm. The compaction factor of MWC without SP increased by 5.8% compared to NWC with optimized 1% SP. There is no significant effect on the compaction factor of concrete at 15 and 30 min after magnetization. This phenomenon is because the MW needs only a lower volume of water surrounding the cement particles to activate the hydration process without segregation and bleeding on concrete .The usage of MW in concrete enhances its strength and improves the quality of the NW. Using magnetic water instead of normal water helps to produce sustainable concrete with reduced cement content and clean compared to the methods above, such as incorporating nanomaterials or chemical admixtures .The split tensile strength of the concrete specimen prepared (NW with optimized 1% SP and MW without SP) and cast after 7, 14 and 28 days, is illustrated in Similar to the strength improvement in compressive test results, the split tensile strength of concrete specimens with the MW, irrespective of all ages was higher than that of the specimens prepared with NW. The 28th day split tensile strength values for the specimen with the MW were increased by 8.9%.The concrete sample cast with the NW consisting of 1% SP and the MW consisting of 0% SP was tested for SEM analysis for the instant duration. Water clusters may be broken up into single molecules or smaller clusters by the process that incorporates magnetic force in the magnetization of the water. Therefore, the activity of water gets improved. Hence, hydration can improve concrete strength more efficiently . Figure The EDAX analysis of MWC shows that the major portion of silica (31.95%) and a minimal amount of calcium (1.40%) are present in MWC compared to the NWC. The lower content of Ca and Mg shows the higher removal of hardness scale through magnetization, and the magnetic field tends to weaken the hydrated ions in calcium carbonate solution. Coey and Cass ,49 reveaanalysis .Moving fluids generate conductivity due to the magnetic field’s influence on water, leading to stresses on the fluids and changes in concentration. The physicochemical properties of the water molecules change due to the presence of kinetic energy in water particles up to some extent, which leads to the breakdown of water clusters into smaller ones. In normal water, water molecules are bigger in size and present in clustered form. When exposed to a magnetic field, the water molecules are disintegrated into discrete smaller molecules. The smaller distinct water molecules of magnetized water disperse uniformly in the concrete mix, reach each and every cement particle, and enhance the hydration process. Penetration of water molecules into the whole mass of concrete helps mobility of the binding materials and improves the workability of the concrete mix with a low water-cement ratio. In the concrete combination, the molecules have positive and negative parts. The positive part is loaded onto the cement particles and surrounds them. The cement particles’ electrical charges are turned negative by the magnetic field. This causes the cement particles to be separated and dispersed from one other, as shown in Magnetized water acts as a water reducing agent. Hence it can be very well used in the preparation of concrete mix without the addition of super plasticizer (SP) to improve the workability of concrete mix.Increase in the exposure duration of water to magnetic field improves the workability of concrete mix as compared to the workability of NWC mix with 1% SP.The slump value of concrete mix prepared with magnetized water obtained from instant exposure to a magnetic field and without the addition of super plasticizer is 96 mm whereas the slump value of normal water concrete mix with 1% SP is 98 mm. This proves that magnetized water in concrete mix without the addition of SP helps to realise a slump value more or less equal to that of normal concrete mix with 1% SP.The slump value of the MWC with 1% SP is 37% greater than that of the NWC with 1% SP.Utilizing the MW within 20 min after magnetization can be recommended to achieve the desired workability without SP.The improvement in compressive strength and split tensile strength of magnetized water concrete specimens amounts to 12% and 8.9%, respectively, as compared to that of NWC with 1% SP specimens.Microstructure development shows that the amount of CSH is larger and its morphology becomes denser and less porous with MWC mix.When concrete consisting of MW without SP and 30% of cement volume is replaced using granite powder waste, this improves the strength properties of M40 grade concrete.The proposed approach helps improve water quality in the concrete industry due to the water magnetization, which directly enhances the quality and life span of the structures. Moreover, the proposed technology can be used to achieve a sustainable and eco-friendly building structure.The experimental results show that the MFTW enhances the water parameters’ activation to improve the concrete’s strength when the MW is used for mixing. The following conclusions were reached:


Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a systemic immune-mediated condition that can cause fibroinflammatory lesions in multiple organs. Approximately 35% of IgG4-RD patients have some symptoms in the chest and IgG4-related lung disease (IgG4-RLD) is observed in about 10% of IgG4-RD cases. In addition, it is thought that glucocorticoid therapy is effective for IgG4-RD and IgG4-RLD. It is difficult to diagnose IgG4-RLD complicated with another lung disease.An 85-year-old Japanese man was hospitalized due to pulmonary consolidations just below the pleura in chest computed tomography while being treated with antibiotics. Previously, an upper lobectomy of the right lung was performed for an upper lung mucinous adenocarcinoma, and he was diagnosed with chronic obstructive pulmonary disease. Although he took antibiotics before admission, C-reactive protein levels were elevated.IgG4 levels were also elevated , and lung biopsy histology showed an abundance of IgG4-positive plasma cell infiltration; about 40% of the affected area was occupied by such infiltration. Based on such findings, we finally diagnosed him as IgG4-RLD.We administered 20 mg/d prednisolone.About 2 weeks after administration of prednisolone by intravenous injection, his multifocal pulmonary consolidations just below the pleura were markedly improved and his pulmonary symptoms disappeared. Four weeks after glucocorticoid therapy, IgG4 levels decreased from 831 mg/dL (peak) to 547 mg/dL.We should consider IgG4-RLD, a rare disease, when lesions are detected as pulmonary consolidations near the pleura and are unresponsive to antibiotic therapy. Glucocorticoid therapy, however, is very effective for such IgG4-RLD. According to previous reports, approximately 35% of IgG4-RD patients have some symptoms in the chest and IgG4-related lung disease (IgG4-RLD) is observed in about 10% of IgG4-RD cases.–5 Glucocorticoid therapy is effective for IgG4-RD and IgG4-RLD.Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a systemic immune-mediated condition that can cause fibroinflammatory lesions in multiple organs and is characterized by fibrosis with prominent lymphoplasmacytic infiltration and dense IgG4-positive plasma cells based on histopathological features.,7 inflammatory pseudotumor, and interstitial pneumonia. In addition, the lesion of IgG4-RLD is sometimes observed near the pleura.,10 Therefore, it is difficult to diagnose IgG4-RLD in subjects who have another lung disease.On the other hand, there are few reports of IgG4-RLD complicated with another lung disease such as primary lung cancer,4/μL (435–555 × 104/μL); hemoglobin, 11.5 g/dL (13.7–16.8 g/dL); platelet, 23.3 × 104/μL (15.8–34.8 × 104/μL). Liver function was almost within normal range, but renal dysfunction was observed: γ-glutamyl transpeptidase (γ-GTP), 25 U/L (13–64 U/L); alkaline phosphatase (ALP), 304 U/L (106–322 U/L); aspartate aminotransferase (AST), 25 U/L (13-30 U/L); alanine aminotransferase (ALT), 10 U/L (10–42 U/L); creatinine (CRE), 1.65 mg/dL (0.65–1.07 mg/dL); blood urea nitrogen (BUN), 52 mg/dL (8–20 U/L). Although he took antibiotics (500 mg of levofloxacin) before admission, his C-reactive protein (CRP) level was high on admission . We changed the antibiotics to 0.6 g of biapenem. We checked various lung disease markers, because his chest CT revealed multifocal pulmonary consolidations just below the pleura . Based on such findings, we finally diagnosed him as IgG4-RLD. In this case, any other organs were not involved in IgG4-related disease including autoimmune pancreatitis and Mikulicz disease, and there were not any other autoimmune diseases.An 85-year-old Japanese man was hospitalized for the treatment of pulmonary consolidations observed just below the pleura in chest computed tomography (CT), after receiving antibiotics (500 mg of levofloxacin) for 5 days as an outpatient. His history included right upper lung mucinous adenocarcinoma and resulting upper lobectomy of the right lung and a diagnosis of chronic obstructive pulmonary disease (COPD) at age 83. He was a heavy smoker  and moderate drinker before experiencing lung mucinous adenocarcinoma after which he stopped both smoking and drinking. His vital signs were as follows: temperature, 36.6°C; blood pressure, 102/54 mm Hg; heart rate, 92 bpm; oxygen saturation, 92% (room air). As shown Table In general, IgG4-related disease responds well to glucocorticoid therapy. Therefore, we started 20 mg/d of prednisolone. About 2 weeks after administration of prednisolone by intravenous injection, his multifocal pulmonary consolidations just below the pleura were markedly improved  related diseases. Furthermore, many cases of IgG4-RLD have been reported as non-IgG4-RLD, because of the difficulty of its diagnosis. These results strengthen the idea once more that in diagnosis of IgG4-RLD, it is important to exclude other diseases, and that differential diagnosis is a very difficult task based on symptoms and image inspection. From this point of view, we think that the present case would be worth reporting.It is known that subjects with IgG4-RD have various symptoms and show a variety of organ damage to varying degrees. To address the complexity of IgG4-RD, the EULAR/ACR 2019 Classification for IgG4-RD was proposed. It is also difficult to differentiate IgG4-RLD from Castleman disease, however, obvious lymph node enlargement was not observed at that time and with the help of pathologists we ruled out Castleman disease. Finally, the direct confirmation of IgG4-positive plasma cell infiltration in the bronchoscopy and lung biopsy of our patient allowed diagnosis of IgG4-RLD, although in general it is difficult to diagnose IgG4-RLD in subjects complicated with another lung disease.In our patient, at first, we suspected an infectious disease because CRP levels were elevated. However, antibiotic therapy with 500 mg of levofloxacin for 5 days as an outpatient was not effective. In addition, our patient was suspected to have drug-induced pneumonia, because his lung shadows did not change after treatment with antibiotics. Elevated KL-6 concentrations and drug-induced pneumonia suggested complications of interstitial pneumonia at that time. Switching form levofloxacin to 0.6 g of biapenem did not change his pulmonary consolidations. We did not consider that both pulmonary infection and drug-induced pneumonia were causes of pulmonary consolidations. Next, it was important to exclude the possibility of recurrence of mucinous adenocarcinoma. Therefore, we performed bronchoscopy and lung biopsy of pulmonary consolidations just below the pleura. Histological examination of his lung biopsy showed an abundance of IgG4-positive plasma cell infiltration which was compatible with IgG4-RLD feature. On the other hand, he had COPD and he was a heavy smoker before experiencing lung mucinous adenocarcinoma. Since COPD is often complicated with thickness of bronchial walls, it is difficult to distinguish COPD from a bronchovascular type of IgG4-RLD. Our lung findings were multifocal pulmonary consolidations just below the pleura, which were progressive for about 4 months. Fortunately, they were detected during a follow-up screening after upper lobectomy of the right lung. It is rare to experience such lung findings and IgG4-RLD. Therefore, we think that it is important to check IgG4 levels upon observing such multifocal pulmonary consolidations.The features of IgG4-RLD lung lesions in chest CT are categorized as solid nodular type, round shaped ground glass opacity type, alveolar interstitial type, and bronchovascular type, with the most typical being bronchovascular type.Taken together, we should bear in mind the possibility of formation of multifocal pulmonary consolidations near the pleura in subjects with IgG4-RLD. In this case, IgG4-RLD detected as pulmonary consolidations just below the pleura in chest CT was unresponsive to antibiotic therapy. We should know that in such a case there is a possibility of IgG4-RLD and that glucocorticoid therapy is effective for IgG4-RLD lesions.We thank Dr Askew David  for the English Language editing and review.TA is the guarantor of this work and, as such, had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy. HT, TA, HT, KK, and YM researched the data and conducted inspections. HT, TA, HT, KK, and YM were in charge of treatment during hospitalization. HK, TO, NO, and KT reviewed and edited the manuscript. HT, TA, HT, KK, YM, HK, TO, NO, and KT contributed to discussion.Conceptualization: Takatoshi Anno.Data curation: Hitomi Tanaka, Takatoshi Anno, Haruka Takenouchi, Katsumasa Koyama.Formal analysis: Hitomi Tanaka, Takatoshi Anno, Haruka Takenouchi, Katsumasa Koyama.Investigation: Hitomi Tanaka, Takatoshi Anno, Haruka Takenouchi, Katsumasa Koyama.Writing – original draft: Takatoshi Anno, Hideaki Kaneto.Writing – review & editing: Takatoshi Anno, Hideaki Kaneto, Toru Oga, Yasumasa Monobe, Koichi Tomoda.