As the United States fights a rising tide of antibiotic resistance, various strategies are being employed across diverse settings to improve how family physicians and other clinicians prescribe antimicrobials to their patients. Ever a proponent of patient-centered, evidence-based care, the antibiotics policy the AAFP has developed, for example, acknowledges that all antibiotic prescribing should be based on best practices and encourages only appropriate use of these drugs.
A study(www.cambridge.org) published in the November issue of Infection Control & Hospital Epidemiology examined antimicrobial prescribing practices among residents in family medicine and internal medicine, as well as hospitalist physicians. The study found that for three common infections, family medicine residents who received antibiotic stewardship education beyond that included in their residency training were more likely than their peers who received only that baseline training to prescribe the correct drug for the proper length of time.
These findings suggest that adding this expanded educational experience to the standard curriculum can lead to better patient care and could help frame how future family medicine residents learn about appropriate use of antimicrobials.
The study reviewed antibiotic prescribing practices for adult patients admitted at a community teaching hospital between July 1, 2016, and June 30, 2017. Patients were included in the study if they were diagnosed at discharge with pneumonia, cellulitis or urinary tract infection and met other related criteria. A total of 1,572 patients were screened; 295 met the inclusion criteria.
The hospital's antimicrobial stewardship program was co-led by an infectious diseases physician and a clinical pharmacist trained in infectious diseases. Its empiric antimicrobial therapy guidelines were based on recommendations from the Infectious Diseases Society of America, supplemented by local susceptibility patterns for different pathogens and literature updates.
- New research has found that family medicine residents who received extra training in antimicrobial stewardship more frequently prescribed the correct drug for the appropriate duration of therapy than did residents in other specialties who received only baseline stewardship training.
- Family medicine residents were significantly more likely than their peers in other specialties to prescribe antimicrobials for the appropriate duration to treat pneumonia, cellulitis and urinary tract infections.
- The study authors suggested that inserting focused antimicrobial stewardship training into program curricula could increase adherence to institutional guidelines.
Three physician services were studied: family medicine resident service, internal medicine resident service and hospitalist service. All three groups received identical baseline ASP education, along with daily antibiotic prescribing audits and feedback provided by clinical pharmacists who attended patient care rounds and assisted with medication selection.
In addition, each group received different types of supplemental education.
- Family medicine residents received an additional layer of training that consisted of biweekly stewardship-focused rounding and education sessions provided by the ASP leaders. Sessions typically lasted between 15 and 30 minutes and focused on currently admitted cases, with residents receiving instruction on topics such as empiric therapy, duration of therapy, new literature or interpretation of diagnostic testing results.
- Internal medicine residents received two additional education sessions provided during grand rounds by an infectious diseases physician throughout the residency year.
- Hospitalists, who served as a control group, received ASP education at new-hire orientation and twice a year from the ASP co-leaders.
When comparing all three groups, guideline-concordant antibiotic selection was similar for all diagnoses at hospital admission and at discharge. When considering all diagnoses and prescribing services, however, the researchers observed notable differences in prescribing practices among groups.
At admission, the percentage of patients who received guideline-concordant antibiotic selection empirically was highest in FM residents (87.5%), although the differences among the three groups (87% for IM residents, 83.8% for hospitalists) were not statistically significant.
For all three infections a significantly higher percentage of FM residents -- 74% -- prescribed antibiotics for the appropriate duration of therapy than did IM residents or hospitalists (56.5% and 44.6%, respectively).
Finally, appropriate definitive antibiotic selection at discharge was highest among FM residents (92.4%), although the difference between FM residents and the other groups (89.9% for hospitalists, 89.1% for IM residents) was not statistically significant.
The study authors attributed the FM residents' higher rates of prescribing antibiotics for the appropriate DOT to the additional training they received.
"These results suggest that more frequent and multifaceted interactions with the ASP team may positively impact guideline-concordant prescribing habits," they wrote.
The authors added that the constant contact with ASP leaders likely reinforced the hospital's own guidelines. They speculated that having an expert on-site to provide face-to-face education that involved patient cases was more effective than lectures or prescribing audits and feedback alone.
"Adding dedicated stewardship-focused rounds into the graduate medical curriculum was associated with increased adherence specifically with DOT prescribing," the authors concluded. "Antimicrobial stewardship programs should seek out opportunities to incorporate consistent teaching activities, such as patient case simulations, into graduate medical education on top of routine provider education and audit with feedback."
FP Expert's Perspective
Brian Bachelder, M.D., of Mount Gilead, Ohio, a member of the AAFP's Commission on Education, told AAFP News that although he wasn't surprised by the study's findings, he did see a positive aspect to the additional education family medicine residents received.
"Many aspects of medicine benefit from repetition and oversight, especially when complexity meets multiple choices and temptation exists for overutilization," Bachelder said. "This model creates a pathway for new variations in antimicrobial training."
But extra training requires extra time, and finding that extra time could pose a challenge for residency directors.
"Their problem is the broad array of information that must be taught during the three-year family medicine residency program and where to best prioritize their time and efforts. It is only one small piece of an immense amount of information that must be mastered," he said.
Still, Bachelder thought that even FPs who have been in practice for a while could find value in the additional training.
"With changing antibiotic resistance patterns, it shows that even seasoned physicians would likely benefit from a refresher course in antibacterial prescribing," he said.
Related AAFP News Coverage
Is That Antibiotic Prescription Really Necessary?
Study Finds One in Four Prescriptions Are for Inappropriate Indications