By Dean L. Winslow, MD, FACP, FIDSA
Professor of Medicine, Division of General Medical Disciplines, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine
Dr. Winslow reports no financial relationships relevant to this field of study.
SYNOPSIS: In an observational study conducted at an academic medical center in London, researchers looked at factors involved in decision-making. The presumptive diagnosis of infection by the emergency department (ED) influenced decision-making by both medical and surgical admitting teams. Medical teams tended to use a multidisciplinary approach to antibiotic decision-making. Surgical teams often delegated antibiotic decision-making to the most junior members of the surgical team.
SOURCE: Charani E, Ahmad R, Rawson TM, et al. The differences in antibiotic decision-making between acute surgical and acute medical teams: An ethnographic study of culture and team dynamics. Clin Infect Dis 2018; doi: 10.1093/cid/ciy844. [Epub ahead of print].
This observational study was conducted in London at an academic medical center, and it incorporated more than 500 hours of observation over a two-year period. The researchers examined cultural determinants of antibiotic decision-making among acute medical teams and surgical teams. In medicine, the decision-making process could be characterized as collectivist (using input from pharmacists, infectious disease specialists, and medical microbiology teams), informed by policy, and with an emphasis on de-escalation of therapy. The investigators noted that among acute medicine teams, gaps in antibiotic decision-making mainly occur during the transition between the emergency department and inpatient teams. In these transitions, the ownership of the antibiotic prescription can become lost.
For the surgery teams, the priorities are divided among the operating room, outpatient clinic, and ward settings. In the ward, senior surgeons are absent frequently, and complex medical decisions often are left to junior staff. The result is defensive decision-making, which leads to antibiotic use that is prolonged and inappropriate. In medicine, the initial diagnosis of infection made in the emergency department influenced subsequent prescription of antibiotics. In the surgery setting, decision-making about antibiotics is thought of as a nonsurgical intervention that house staff or other specialties can manage.
This study really resonated with me and reinforced many of my pet peeves about antibiotic overprescribing in 21st century medicine in the United States. I was heartened that our British internal medicine colleagues seem to rely on “collectivist” decision-making to prescribe antibiotics more than we do in the United States. Although it is true in the United States that surgical specialists often delegate antibiotic prescription to the more junior members of the team, I am not sure that they perform that much worse than our medicine teams do.
I have become increasingly convinced that much of the over-prescription of antibiotics by many doctors in the United States actually is driven by fear. Although guidelines such as the Surviving Sepsis Campaign guidelines have increased awareness of early recognition and appropriate treatment of sepsis, I am concerned that the application of these guidelines in the absence of discernment has resulted in “fear-based” over-prescription of broad-spectrum antibiotics. (One example I give is the common setting of a hospitalized patient who develops massive hemorrhage, is noted incidentally to have leukocytosis, and then reflexively is given vancomycin plus meropenem since they “don’t want to miss sepsis.”)
I hope that over the next few months the concerns of many infectious disease specialists will be recognized and we can work with our critical care medicine colleagues to develop truly evidence-based guidelines for the management of sepsis.1
- IDSA Sepsis Task Force; Kalil AC, Gilbert DN, Winslow DL, et al. Infectious Diseases Society of America (IDSA) Position Statement: Why IDSA did not endorse the Surviving Sepsis Campaign guidelines. Clin Infect Dis 2018;66:1631-1635.