Internal Medicine Resident Perspectives Regarding Broad-Spectrum Antibiotic Usage

Open Forum Infectious Diseases, Apr 2017

Focus groups held with internal medicine residents discussed their perspectives regarding broad-spectrum antibiotic (BSA) usage. Residents knew of BSA-associated adverse events, but they did not associate such events with increased patient morbidity and mortality, and they were more likely to use BSA in situations with diagnostic uncertainty and sick patients.

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Internal Medicine Resident Perspectives Regarding Broad-Spectrum Antibiotic Usage

Internal Medicine Resident Perspectives Regarding Broad- Spectrum Antibiotic Usage Received 1 4 November 1 4 editorial decision 1 4 March 1 4 accepted 1 2 4 April 1 4 . Presented in part: IDWeek 1 4 San Francisco 1 4 California. Correspondence: A. M. Laake 1 4 Martinsburg VAMC 1 4 Butler Ave. 1 4 Martinsburg 1 4 0 George Washington University School of Public Health , Washington, DC , USA 1 Published by Oxford University Press on behalf of Infectious Diseases Society of America 2017. DOI: 10.1093/ofid/ofx060 2 Department of Medicine, George Washington University Medical Center , Washington, DC , USA 3 Section of Infectious Diseases, Medical Service, Veterans Affairs Medical Center , Washington, DC , USA 4 Ann M. Laake Focus groups held with internal medicine residents discussed their perspectives regarding broad-spectrum antibiotic (BSA) usage. Residents knew of BSA-associated adverse events, but they did not associate such events with increased patient morbidity and mortality, and they were more likely to use BSA in situations with diagnostic uncertainty and sick patients. - Prescribing antibiotics is a complex behavior influenced by national and local culture and individual behavior patterns [ 1 ]. Qualitative research has explored these influences [ 2 ]. Understanding influences affecting initiation of broad-spectrum antibiotic (BSA) coverage is crucial in developing effective antimicrobial stewardship programs. In academic training centers in the United States, internal medicine residents (IMRs) supervised by attending physicians typically prescribe antibiotics. The American College of Graduate Medical Education (ACGME) has implemented the “Milestone” program, a competency-based system requiring IMRs to manage “patients with progressive responsibility and independence” [ 3 ]. This system makes IMRs ideal targets for stewardship interventions because they are responsible for most antibiotic prescriptions while also forming prescribing habits. An estimated 37% of such prescriptions are inappropriate; optimizing them could decrease rates of Clostridium difficile infection (CDI) and mitigate selective pressure contributing to antimicrobial resistance [ 4–6 ]. Utilizing qualitative methodology, we examined motivations for prescribing empiric coverage and perceptions regarding BSA usage in IMRs in a US hospital. Quantitative Data Demographic data, including PGYs, genders, and ARP enrollments, were collected for all IMRs at each focus group session. The researchers conducted all analyses with χ2, 2-tailed tests, accepting a P value of <.05 (SPSS, version 21; SPSS Inc., Chicago, IL). Qualitative Analysis Three researchers (A.M.L., G.B., and J.P.) first reviewed the initial transcripts together and developed codes through BRIEF REPORT • OFID • 1 consensus. Codes were then applied to the transcripts by quotes per IMR; PGY-3: 8 quotes per IMR; PGY-1: 5 quotes per each researcher individually. Next, researchers met colIMR; P  <  .0001); however, researchers found no difference in lectively to compare individual coding applications and the frequency with which specific codes were identified among achieve group consensus. Finally, a content analysis of the the different years. group’s consensus codes was used to develop emergent-specific themes (Table 1). The frequency of responses represent unique responses given by individual study participants to which researchers applied that code over the course of the recorded sessions. RESULTS Forty-eight IMRs participated over the 8-month study period; no IMRs declined to participate in the focus groups. Sixty percent of the participants were PGY-1, 17% were PGY-2, and 23% were PGY-3 IMRs. Fifty-four percent of participants were female. Researchers found no difference in the frequency with which specific codes were identified among the 4 ARPs (data Themes Identified From Focus Group Participant Analysis Theme 1: Factors That Influenced Broad Spectrum Antibiotics Use by Internal Medicine Residents The IMRs cited many different influences in their responses (64 responses) related to decisions about BSA usage, including epidemiological risk factors for resistant bacteria, appeasement of patients and attending physicians, fear of liability, and even convenience. However, the 2 most commonly mentioned influences were diagnostic uncertainty (22 responses) and fear regarding how “sick” the IMR perceived the patient to be (22 responses). Theme 2: Consequences of Antibiotic Spectrum Choice not shown). The PGY-2 participants contributed proportionally There were also many responses about the consequences of more comments than participants from other years (PGY-2: 11 antibiotic spectrum choice (22 responses). Patient morbidity and mortality was discussed in the responses, but this was associated exclusively with choosing too narrow of an antibiotic spectrum (8 responses). The IMRs connected the immediate consequences of inappropriately narrow-spectrum antibiotic use an (...truncated)


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Laake, Ann M., Bernabe, Gayle, Peterson, James, Liappis, Angelike P.. Internal Medicine Resident Perspectives Regarding Broad-Spectrum Antibiotic Usage, Open Forum Infectious Diseases, 2017, Volume 4, Issue 2, DOI: 10.1093/ofid/ofx060