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.

Rational antibiotic selection might be compromised by a culture of professional etiquette.

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.

3 Responses to “Broad Is Best? The Culture and Etiquette of Antibiotic Selection in the Training Environment”

  1. “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.”

    Etiquette aside, this is part of the “mindless” culture that promotes antibiotic overuse, widespread development of resistance, and frequent complications – sometimes fatal, e.g. C. difficile colitis.

    Use of the declarative verbs “deserves”, “needs”, “requires”, “must have” etc. implies that there is unconditional benefit, and that it would be unconditionally bad not to do something. We almost never have that certainty.

    While I accept the notion for someone with S. aureus, S. pneumoniae, or N. meningitidis bacteremia, I do not accept it for a patient with fever but little or no evidence of antibiotic-sensitive (bacterial) infection.

    Furthermore, most comparisons of antibiotic regimens (single or multiple) are designed by the manufacturers, and run by Key Opinion Leaders paid by the manufacturers. Most are “equivalency” studies in small populations with no long term follow-up. Antibiotic choices affect not only the individual who receives them, but potentially anyone else on Earth – unlike the use of other drugs except antivirals.

    Young doctors interested in best helping not only their own patients, but also preserving the possibility that the antibiotics may be useful in future might consider a revolutionary strategy:

    Try reading the experimental evidence about antibiotics yourself. See if you can find any unpublished trials. Compare the results of trials with the results you are aiming for in your own patients (or might yourself desire). Then think also about the cost of what you are doing, and who has to pay for it (probably someone working equally hard but earning less than you do).

    A few antibiotic assessments from the period 1998-2008 or so are available under Therapeutics Letters or drug assessment documents at our website:

    Tom Perry, M.D., FRCPC

  2. Nirav Patel says:

    I applaud your insights. You specifically highlight some of the practical challenges of antibiotic stewardship. I think most physicians/residents/medical students agree that antibiotic stewardship is an important concept in preserving antibiotic use for the future, especially at a theoretical level. However, when it comes to MY patient, right here, right now, I want the “best” for them.

    One issue that prescribers gloss over is the risk of antibiotic therapies. We need to further emphasize to them that antibiotic therapy is not without risk to your patient, right here, right now. Perhaps, I may be off service, but a patient who was inappropriately treated with antibiotics previously, and now is readmitted with a superinfection, or a complication from antibiotic therapy, such as C. difficile disease, has clearly not had the best possible outcome. This can occur on a shorter time scale as well. Plenty of patients are started on antibiotics, just in case, and plenty of times, “nothing” bad happens. But, one case of toxic megacolon could change your outlook. Should we let it get to that stage before intervention?

    Culture change is, as you state, the biggest problem here. I think the first step toward that is accepting that antibiotics are not without consequence (both societal and for individual patients), and that my prescribing practices can lead to adverse effect.

    Perhaps another realization is that starting antibiotics does not mean being committed to antibiotics. If new clinical data achieved over a period of observation leads to an alternate diagnosis, then antibiotics can be stopped. As Drs. Paterson and Rice state, we must “have the courage to reduce antimicrobial exposure if microbiologic data fail to confirm the presence of bacterial infection.” (Clin Infect Dis 2003;36:1006-12)

    Lastly, one of the mistakes made by housestaff is assuming “broad” means “potent”. I still get push-back on a drug like Vancomycin, because the assumption is that since it “works” on MRSA that it must be “potent” for MSSA as well. Clearly this is not the case.

    A number of challenges face the antibiotic steward. Again, I appreciate your comments in reflecting the “real world” of antibiotic prescribing. We need to continue to have these discussion, continue to renew our focus, and continue to find gaps in our knowledge base if we want to have antibiotics available 40 years from now.

  3. Paul Bergl, M.D. says:

    I appreciate the insightful responses. I completely agree with the sentiments in these two comments.

    I don’t want to excuse residents the world over, but many house officers must weigh their supervisor’s perceptions as they are making clinical decisions. In my opinion, this weight of expectations factors heavily into antibiotic prescribing.

    I have often faced situations in which antibiotics were unnecessary or unnecessarily broad. Unfortunately, some physicians are still too flippant about antibiotics. If these flippant physicians happen to be my attendings, I am pressured to oblige with the decision to take a heavy hand toward potential infections without respect for potential complications.

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