August 13th, 2013
Broad Is Best? The Culture and Etiquette of Antibiotic Selection in the Training Environment
Friends and colleagues, welcome to the new academic year! I am delighted to be a chief resident blogger for NEJM Journal Watch for the coming year. Without further ado, let’s discuss residents’ use of antibiotics.
Antibiotic selection can either be one of the most anguishing or most mindless decisions that an internal medicine resident makes. For some patients, defaulting to a broad spectrum makes sense. A patient with neutropenic fever who is in shock deserves stat delivery and subsequent administration of almost every antibiotic in the pharmacy — at least until culture data can guide more informed decisions.
On the other hand, some patients require a little more deliberation in nuance. Most residents have probably dealt with some degree of self-torment in choosing antibiotics.
- Is this really a community-acquired infection? A true community dweller is hard to find these days, and didn’t I just read something about infections like MRSA and C. difficile making their way out into the community?
- Is this antibiotic regimen really the correct spectrum? I know my Sanford guide says so, but this patient just looks too sick to use a narrower spectrum. Maybe I’ll broaden just so I don’t miss something, and I’ll let my attending decide when to narrow.
- I know not all fevers are from infection, but how can I justify withholding antibiotics on rounds tomorrow? What if my patient ends up in the ICU because I didn’t start antibiotics?
- The pharmacy says the antibiotic I want to use is restricted for use by the Infectious Disease consultants only. But my patient needs this antibiotic… Besides, the most critical thing I can do for a septic patient is give them broad-spectrum antibiotics as quickly as humanly possible, right?
A recent NEJM Journal Watch article broaches these topics and offers a little solace to the conscientious and excessively deliberative house officer.
Abigail Zuger reviewed an article by Charani et al in Clinical Infectious Diseases that evaluated prescribing practices in four London hospitals. The authors interviewed nurses, pharmacists, and physicians and identified that a “prescribing etiquette” is woven into the culture of medicine. There were several aspects to this culture that we’ve all likely experienced:
- Colleagues do not want to question another’s autonomy. For example, a pharmacist might defer to a senior attending’s antibiotic selection even if the pharmacist perceives it as irrational.
- Everyone tolerates noncompliance with policies. Thus, even though a stewardship plan is in place, stewards might be lenient with policies and might not offer much of a hindrance to poor prescribing practices.
- Even though trainees write most of the orders for antibiotics, the approach to antibiotic therapy is gleaned from attendings and consultants. A hospital might have prescribing policies, but trainees are more likely to be influenced by the patterns of other prescribers instead.
This culture probably makes the resident more vulnerable as well. If the antimicrobial stewards are unable to regularly enforce their policies, then the resident has even less leverage. Given this culture and the uncertainty in our own knowledge and skills, who can blame a house officer for the “broad is best” and “more antibiotics are better than less” approaches?
I look forward to your comments.