Clinical Reasoning Behind Antibiotic Use in PICUs: A Qualitative Study.
Journal
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
ISSN: 1529-7535
Titre abrégé: Pediatr Crit Care Med
Pays: United States
ID NLM: 100954653
Informations de publication
Date de publication:
01 03 2022
01 03 2022
Historique:
pubmed:
12
1
2022
medline:
30
4
2022
entrez:
11
1
2022
Statut:
ppublish
Résumé
To describe the reasoning processes used by pediatric intensivists to make antibiotic-related decisions. Grounded theory qualitative study. Three Canadian university-affiliated tertiary medical, surgical, and cardiac PICUs. Twenty-one PICU physicians. None. We conducted field observation during morning rounds followed by semistructured interviews with participants to examine the clinical reasoning behind antibiotic-related decisions (starting/stopping antibiotics, or treatment duration) made for patients with a suspected/proven bacterial infection. We used a grounded theory approach for data collection and analysis. Thematic saturation was reached after 21 interviews. Of the 21 participants, 10 (48%) were female, 15 (71%) were PICU attending staff, and 10 (48%) had greater than 10 years in clinical practice. Initial clinical reasoning involves using an analytical approach to determine the likelihood of bacterial infection. In case of uncertainty, an assessment of patient safety is performed, which partly overlaps with the use of intuitive clinical reasoning. Finally, if uncertainty remains, physicians tend to consult infectious diseases experts. Factors that override this clinical reasoning process include disease severity, pressure from consultants, and the tendency to continue antibiotic treatment initiated by colleagues. Antibiotic-related decisions for critically ill children are complex, and pediatric intensivists use several clinical reasoning strategies to decrease the uncertainty around the bacterial etiology of infections. However, disease severity and patient safety concerns may overrule decisions based on clinical evidence and lead to antibiotic use. Several cognitive biases were identified in the clinical reasoning processes.
Identifiants
pubmed: 35013080
doi: 10.1097/PCC.0000000000002886
pii: 00130478-202203000-00016
doi:
Substances chimiques
Anti-Bacterial Agents
0
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
e126-e135Commentaires et corrections
Type : CommentIn
Informations de copyright
Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Déclaration de conflit d'intérêts
Dr. Lacroix’s institution received funding as a principal applicant for a Canadian Institutes of Health Research grant. The remaining authors have disclosed that they do not have any potential conflicts of interest.
Références
Fischer JE, Ramser M, Fanconi S. Use of antibiotics in pediatric intensive care and potential savings. Intensive Care Med. 2000; 26:959–966
Blinova E, Lau E, Bitnun A, et al. Point prevalence survey of antimicrobial utilization in the cardiac and pediatric critical care unit. Pediatr Crit Care Med. 2013; 14:e280–e288
Ceyhan M, Yildirim I, Ecevit C, et al. Inappropriate antimicrobial use in Turkish pediatric hospitals: A multicenter point prevalence survey. Int J Infect Dis. 2010; 14:e55–e61
Ding H, Yang Y, Chen Y, et al. Antimicrobial usage in paediatric intensive care units in China. Acta Paediatr. 2008; 97:100–104
Dellit TH, Owens RC, McGowan JE Jr, et al.; Infectious Diseases Society of America; Society for Healthcare Epidemiology of America. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007; 44:159–177
Bradley JS, Byington CL, Shah SS, et al.; Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011; 53:e25–e76
Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50:133–164
Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004; 39:1267–1284
Strauss A, Corbin J: Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA, Sage, 1990
Carnevale FA. Authentic qualitative research and the quest for methodological rigour. Can J Nurs Res. 2002; 34:121–128
Guba EG, Lincoln YS: Effective Evaluation. San Francisco, CA, Jossey-Bass Publishers, 1981
Levy R. Croyance et doute: Une vision paradigmatique des méthodes qualitatives. Ruptures. 1994; 1:92–100
Sandelowski M. The problem of rigor in qualitative research. ANS Adv Nurs Sci. 1986; 8:27–37
Morse JM. The significance of saturation. Qual Health Res. 1995; 5:147–149
Sandelowski M. Sample size in qualitative research. Res Nurs Health. 1995; 18:179–183
Warreman EB, Lambregts MMC, Wouters RHP, et al. Determinants of in-hospital antibiotic prescription behaviour: A systematic review and formation of a comprehensive framework. Clin Microbiol Infect. 2019; 25:538–545
Livorsi D, Comer A, Matthias MS, et al. Factors influencing antibiotic-prescribing decisions among inpatient physicians: A qualitative investigation. Infect Control Hosp Epidemiol. 2015; 36:1065–1072
Abbo L, Sinkowitz-Cochran R, Smith L, et al. Faculty and resident physicians’ attitudes, perceptions, and knowledge about antimicrobial use and resistance. Infect Control Hosp Epidemiol. 2011; 32:714–718
Wunderink RG, Srinivasan A, Barie PS, et al. Antibiotic stewardship in the intensive care unit. An Official American Thoracic Society workshop report in collaboration with the AACN, CHEST, CDC, and SCCM. Ann Am Thorac Soc. 2020; 17:531–540
Pickens CI, Wunderink RG. Principles and practice of antibiotic stewardship in the ICU. Chest. 2019; 156:163–171
Simpkin AL, Schwartzstein RM. Tolerating uncertainty - The next medical revolution? N Engl J Med. 2016; 375:1713–1715
Ashby D, Smith AF. Evidence-based medicine as Bayesian decision-making. Stat Med. 2000; 19:3291–3305
Elstein AS, Schwartz A, Schwarz A. Clinical problem solving and diagnostic decision making: Selective review of the cognitive literature. BMJ. 2002; 324:729–732
Eva KW. What every teacher needs to know about clinical reasoning. Med Educ. 2005; 39:98–106
Livorsi DJ, Nair R, Lund BC, et al. Antibiotic stewardship implementation and antibiotic use at hospitals with and without on-site infectious disease specialists. Clin Infect Dis. 2021; 72:1810–1817
Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009; 84:1022–1028
Pelaccia T, Tardif J, Triby E, et al. An analysis of clinical reasoning through a recent and comprehensive approach: The dual-process theory. Med Educ Online. 2011; 16:1
Connors GR, Siner JM. Clinical reasoning and risk in the intensive care unit. Clin Chest Med. 2015; 36:449–459
Hillen MA, Gutheil CM, Strout TD, et al. Tolerance of uncertainty: Conceptual analysis, integrative model, and implications for healthcare. Soc Sci Med. 2017; 180:62–75
Strout TD, Hillen M, Gutheil C, et al. Tolerance of uncertainty: A systematic review of health and healthcare-related outcomes. Patient Educ Couns. 2018; 101:1518–1537
DeForge BR, Sobal J. Intolerance of ambiguity in students entering medical school. Soc Sci Med. 1989; 28:869–874
Burman RA, Zakariassen E, Hunskaar S. Chest pain out-of-hours - An interview study of primary care physicians’ diagnostic approach, tolerance of risk and attitudes to hospital admission. BMC Fam Pract. 2014; 15:207
Baldwin RL, Green JW, Shaw JL, et al. Physician risk attitudes and hospitalization of infants with bronchiolitis. Acad Emerg Med. 2005; 12:142–146
Nevalainen M, Kuikka L, Pitkälä K. Medical errors and uncertainty in primary healthcare: a comparative study of coping strategies among young and experienced GPs. Scand J Prim Health Care. 2014; 32:84–89
Charlin B, Boshuizen HP, Custers EJ, et al. Scripts and clinical reasoning. Med Educ. 2007; 41:1178–1184
Langford BJ, Daneman N, Leung V, et al. Cognitive bias: How understanding its impact on antibiotic prescribing decisions can help advance antimicrobial stewardship. JAC Antimicrob Resist. 2020; 2:dlaa107
Peiffer-Smadja N, Lescure FX, Maatoug R, et al. Re: ‘Determinants of in-hospital antibiotic prescription behaviour’ by Lambregts et al. Clin Microbiol Infect. 2019; 25:635–637
Price LB, Hungate BA, Koch BJ, et al. Colonizing opportunistic pathogens (COPs): The beasts in all of us. PLoS Pathog. 2017; 13:e1006369