Darcy Wooten1,2, Katherine Kahn3,4, Jonathan D Grein3,5, Samantha J Eells1, Loren G Miller1,3. 1. Division of Infectious Diseases, Harbor-UCLA Medical Center, and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California. 2. Division of Infectious Diseases, UCSD Medical Center, San Diego, California. 3. UCLA Clinical and Translational Science Institute, Los Angeles, California. 4. Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, and the RAND Corporation, Santa Monica, California. 5. Department of Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles, California.
Abstract
BACKGROUND: Antibiotic treatment decisions for medically complex patients are complicated, as the risk of undertreatment may be severe, whereas overtreatment may be associated with adverse effects and the emergence of antibiotic resistant pathogens. OBJECTIVE: To determine the influence of patient complexities on providers' decisions to prescribe antibiotics in 3 common hospital-based clinical vignettes. DESIGN: A physician survey. SETTING: Three urban medical centers in Los Angeles County, California. PARTICIPANTS: Hospital-based physicians. MEASUREMENTS: Physicians were presented 3 clinical vignettes, with variations by patient age, comorbidity burden, functional status, and follow-up, and asked to choose the best antibiotic regimen. We described the association of additional patient complexity on the proportion of guideline-adherent antibiotic choices. RESULTS: In the survey, 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with either older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P < 0.01). CONCLUSIONS: In 3 vignettes depicting common clinical scenarios among hospitalized adults, inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities. Treatment guidelines should consider addressing medically complex patients in the context of infection management.
BACKGROUND: Antibiotic treatment decisions for medically complex patients are complicated, as the risk of undertreatment may be severe, whereas overtreatment may be associated with adverse effects and the emergence of antibiotic resistant pathogens. OBJECTIVE: To determine the influence of patient complexities on providers' decisions to prescribe antibiotics in 3 common hospital-based clinical vignettes. DESIGN: A physician survey. SETTING: Three urban medical centers in Los Angeles County, California. PARTICIPANTS: Hospital-based physicians. MEASUREMENTS: Physicians were presented 3 clinical vignettes, with variations by patient age, comorbidity burden, functional status, and follow-up, and asked to choose the best antibiotic regimen. We described the association of additional patient complexity on the proportion of guideline-adherent antibiotic choices. RESULTS: In the survey, 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with either older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P < 0.01). CONCLUSIONS: In 3 vignettes depicting common clinical scenarios among hospitalized adults, inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities. Treatment guidelines should consider addressing medically complex patients in the context of infection management.