Supporting better decision making for acute infection management in secondary care

In a recent study published in BMC Medicine, we set out to explore the way that decisions are made surrounding infection management. We report a study to map the decision making process of medical physicians in secondary care for acute infection management and investigate factors which may hinder or facilitate the effective use of antibiotics.

As a Junior Doctor in the UK with an interest in Infectious Diseases and Microbiology, I am always fascinated by observing senior doctors as they make decisions about the management of infections and how this can subsequently influence junior trainees’ future actions.

Globally, antibiotics are almost unique medicines in that they do not primarily target a host mechanism but instead target micro-organisms that are causing an infection. Unfortunately their lack of specificity means that as well as benefits of therapy, killing of harmful pathogens, there are also harmful consequences. These are the development of toxicity to the host and development of antimicrobial resistance (AMR) by organisms exposed to the antibiotic.

Despite the complexities or antibiotic prescribing, the majority of antibiotics are prescribed by non-experts (i.e. non-infectious diseases specialists). These individuals often do not have formal training in infection management and are often guided by local policies and guidelines.

While these policies are based on local epidemiological data, expert opinion, and the best available evidence they often fail to provide the flexibility required to support decision making when faced by normal variations in clinical practice.

Furthermore, there is a growing body of evidence describing knowledge, attitudes, and cultural determinants of antimicrobial prescribing – all of which have a large influence on the way antibiotics are prescribed.

To address the challenges posed by AMR, the importance of behavior change interventions in improving the long term use of antimicrobials in infection management has been recognized. A greater understanding of the decision pathways taken by prescribers and the influences on these may allow for the development of targeted interventions for specific aspects.

One of the major observations we made was the difficulties the junior prescriber has when making decisions about antibiotic prescribing with a number of factors influencing the choices that they make.

For example, junior trainees have an imbalance of expectation placed upon them, where they are expected not to miss the septic patient and are expected to start antibiotics if infection is suspected. On the other hand they are not expected to stop or de-escalate a patient’s antibiotics, which is seen as a very senior decision.

This not only means that junior trainees often don’t receive feedback about their prescribing decisions, but also creates an imbalance of expectation leading to views such as were reported in our study.

“I’ve got a bit of a nice cushion from all the senior levels about even if I prescribe the wrong antibiotic, I don’t mean of course prescribing penicillin when someone’s penicillin allergic, that’s not what I mean. I mean prescribing for example flucloxacillin when it’s an E.coli bacteria, wrong bacteria, wrong antibiotic of choice or bacteria, but an antibiotic nonetheless.”

“I’m completely disempowered [to stop antibiotics], because they’re so complicated and the consultants who know their patients have their own ways of prescribing. It’s very unusual that anyone would actually explain to you what they’re thinking. I think I’ve had one explanation which was like a ray of sunshine”

Furthermore, issues arise when guidelines are not available for the individual patient situation facing the clinical team. In this scenario much reliance is placed on specialist advice from infection/microbiology experts, however there is often much skepticism about the nature of that advice, especially as the responsibility for the outcome of the advice given often remains with the senior clinician caring for the patient. Therefore, you often get disjointed and different decisions made based on who gives the advice (senior or junior infection / microbiologist) and who the most senior doctor responsible for the patient is.

“They tend to give more of a patient specific approach but the difficulty in that is that they haven’t seen the patient. So they’re sort of just giving you advice over the telephone”
“I think the difficult thing which sometimes arises that microbiology are often the more conservative end of the antibiotic spectrum and say, OK, you’ve had your course, stop and I may agree with that as a registrar. But the problem is that actually suggesting for me to do it is the wrong person because it’s my decision once I’ve seen the patient on the ward round, but once you’ve got a consultant [microbiologist] that’s come and ratified the decision then that becomes their decision”

Overall, infection management is a challenging and complex process. There is currently little evidence to support how clinicians make decisions. With emerging understanding of common steps taken by clinicians during infection management our hope is that targeted interventions can be developed that have maximal impact of different stages of the decision making process. This may help support appropriate antimicrobial prescribing and justify different interventions tested in clinical practice, such as electronic clinical decision support tools.

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