Abstract
BackgroundQualitative work has described the differences in prescribing practice across medical and surgical specialties. This study aimed to understand if specialty impacts quantitative measures of prescribing practice.MethodsWe prospectively analysed the antibiotic prescribing across general medical and surgical teams for acutely admitted patients. Over a 12-month period (June 2016 – May 2017) 659 patients (362 medical, 297 surgical) were followed for the duration of their hospital stay. Antibiotic prescribing across these cohorts was assessed using Chi-squared or Wilcoxon rank-sum, depending on normality of data. The t-test was used to compare age and length of stay. A logistic regression model was used to predict escalation of antibiotic therapy.ResultsSurgical patients were younger (p < 0.001) with lower Charlson Comorbidity Index scores (p < 0.001). Antibiotics were prescribed for 45% (162/362) medical and 55% (164/297) surgical patients. Microbiological results were available for 26% (42/164) medical and 29% (48/162) surgical patients, of which 55% (23/42) and 48% (23/48) were positive respectively. There was no difference in the spectrum of antibiotics prescribed between surgery and medicine (p = 0.507). In surgery antibiotics were 1) prescribed more frequently (p = 0.001); 2) for longer (p = 0.016); 3) more likely to be escalated (p = 0.004); 4) less likely to be compliant with local policy (p < 0.001) than medicine.ConclusionsAcross both specialties, microbiology investigation results are not adequately used to diagnose infections and optimise their management. There is significant variation in antibiotic decision-making (including escalation patterns) between general surgical and medical teams. Antibiotic stewardship interventions targeting surgical specialties need to go beyond surgical prophylaxis. It is critical to focus on of review the patients initiated on therapeutic antibiotics in surgical specialties to ensure that escalation and continuation of therapy is justified.
Highlights
Qualitative work has described the differences in prescribing practice across medical and surgical specialties
During the ward rounds observed in the study, prescribed antibiotics were reviewed in 143/162 (88%) of medical and 111/164 (68%) of surgical patients
Antibiotics were started in the absence of a) fever and b) abnormal white blood cell count in 32/162 (19%) of medical and 32/164 (19%) of surgical patients
Summary
Qualitative work has described the differences in prescribing practice across medical and surgical specialties. Charani et al Antimicrobial Resistance and Infection Control (2019) 8:151 decision-making occurs across different specialties, and describes how and why clinicians make antibiotic prescribing decisions, it does not address what the effect of these contextual differences are on clinical practice. In this study we set out to investigate antibiotic prescribing in medical and surgical specialties. This study set out to investigate whether there was significant variation in the antibiotic prescribing practices between surgical and medical teams. This knowledge is critical in order to shift from a one size fits all approach to one that recognizes the specific challenges facing clinicians treating infections across different specialties
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