![\"\"](\"http:\/\/blogs.nejm.org\/general-medicine\/wp-content\/uploads\/sites\/4\/2013\/08\/microbiologist_big1.jpg\")
<\/a>Rational antibiotic selection might be compromised by a culture of professional etiquette.<\/p><\/div>\n
On the other hand, some patients require a little more deliberation in nuance. Most residents have probably dealt with some degree of self-torment in choosing antibiotics.<\/p>\n
- \n
- Is this really<\/strong> <\/i><\/b>a community-acquired<\/i><\/b> infection? A true community dweller is hard to find these days, and didn\u2019t I just read something about infections like MRSA and C. difficile<\/i> making their way out into the community?<\/li>\n
- Is this antibiotic regimen really<\/strong> the correct<\/i><\/b> spectrum<\/i><\/b>? I know my Sanford guide says so, but this patient just looks too sick to use a narrower spectrum. Maybe I\u2019ll broaden just so I don\u2019t miss something, and I\u2019ll let my attending decide when to narrow.<\/li>\n
- I know not all fevers are from infection, but how can I justify withholding antibiotics on rounds tomorrow? What if my patient ends up in the ICU because I didn\u2019t start antibiotics?<\/li>\n
- The pharmacy says the antibiotic I want to use is restricted for use by the Infectious Disease consultants only. But my patient needs<\/i><\/b> this antibiotic\u2026 Besides, the most critical thing I can do for a septic patient is give them broad-spectrum antibiotics as quickly as humanly possible, right?<\/li>\n<\/ul>\n
A recent NEJM Journal Watch article broaches these topics and offers a little solace to the conscientious and excessively deliberative house officer.<\/p>\n
Abigail Zuger reviewed<\/a>\u00a0an article by Charani et al<\/a> in Clinical Infectious Diseases <\/em>that evaluated prescribing practices in four London hospitals. The authors interviewed nurses, pharmacists, and physicians and identified that a \u201cprescribing etiquette\u201d is woven into the culture of medicine.\u00a0 There were several aspects to this culture that we\u2019ve all likely experienced:<\/p>\n
- \n
- Colleagues do not want to question another\u2019s autonomy. For example, a pharmacist might defer to a senior attending\u2019s antibiotic selection even if the pharmacist perceives it as irrational.<\/li>\n
- Everyone tolerates noncompliance with policies. Thus, even though a stewardship plan\u00a0is in place, stewards might be lenient with policies and might not offer much of a hindrance to poor prescribing practices.<\/li>\n
- Even though trainees write most of the orders for antibiotics, the approach to antibiotic therapy is gleaned from attendings and consultants. A hospital might have prescribing policies, but trainees are more likely to be influenced by the patterns of other prescribers instead.<\/li>\n<\/ul>\n
This culture probably makes the resident more vulnerable as well. If the antimicrobial stewards are unable to regularly enforce their policies, then the resident has even less leverage. Given this culture and the uncertainty in our own knowledge and skills, who can blame a house officer for the \u201cbroad is best\u201d and \u201cmore antibiotics are better than less\u201d approaches?<\/p>\n
I look forward to your comments.<\/p>\n","protected":false},"excerpt":{"rendered":"
Friends and colleagues, welcome to the new academic year! I am delighted to be a chief resident blogger for NEJM Journal Watch for the coming year. Without further ado, let\u2019s discuss residents\u2019 use of antibiotics. Antibiotic selection can either be one of the most anguishing or most mindless decisions that an internal medicine resident makes. […]<\/p>\n","protected":false},"author":25,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[9,26,31],"class_list":["post-885","post","type-post","status-publish","format-standard","hentry","category-about-residency","tag-antibiotics","tag-evidence-based-medicine","tag-patient-care"],"yoast_head":"\n
Broad Is Best? The Culture and Etiquette of Antibiotic Selection in the Training Environment - Insights on Residency Training<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2013\/08\/broad-is-best-the-culture-and-etiquette-of-antibiotic-selection-in-the-training-environment\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Broad Is Best? The Culture and Etiquette of Antibiotic Selection in the Training Environment\" \/>\n<meta property=\"og:description\" content=\"Friends and colleagues, welcome to the new academic year! I am delighted to be a chief resident blogger for NEJM Journal Watch for the coming year. Without further ado, let\u2019s discuss residents\u2019 use of antibiotics. 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- Is this antibiotic regimen really<\/strong> the correct<\/i><\/b> spectrum<\/i><\/b>? I know my Sanford guide says so, but this patient just looks too sick to use a narrower spectrum. Maybe I\u2019ll broaden just so I don\u2019t miss something, and I\u2019ll let my attending decide when to narrow.<\/li>\n