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.
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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)