Provider Decisions to Treat Respiratory Illnesses with Antibiotics: Insights from a Randomized Controlled Trial

Abstract

RationaleLower respiratory tract illness (LRTI) frequently causes adult hospitalization and antibiotic overuse. Procalcitonin (PCT) treatment algorithms have been used successfully in Europe to safely reduce antibiotic use for LRTI but have not been adopted in the United States. We recently performed a feasibility study for a randomized clinical trial (RCT) of PCT and viral testing to guide therapy for non-pneumonic LRTI.ObjectiveThe primary objective of the current study was to understand factors influencing PCT algorithm adherence during the RCT and evaluate factors influencing provider antibiotic prescribing practices for LRTI.Study DesignFrom October 2013-April 2014, 300 patients hospitalized at a community teaching hospital with non-pneumonic LRTI were randomized to standard or PCT-guided care with viral PCR testing. Algorithm adherence data was collected and multivariate stepwise logistic regression of clinical variables used to model algorithm compliance. 134 providers were surveyed anonymously before and after the trial to assess knowledge of biomarkers and viral testing and antibiotic prescribing practices.ResultsDiagnosis of pneumonia on admission was the only variable significantly associated with non-adherence [7% (adherence) vs. 26% (nonadherence), p = 0.01]. Surveys confirmed possible infiltrate on chest radiograph as important for provider decisions, as were severity of illness, positive sputum culture, abnormal CBC and fever. However, age, patient expectations and medical-legal concerns were also at least somewhat important to prescribing practices. Physician agreement with the importance of viral and PCT testing increased from 42% to 64% (p = 0.007) and 49% to 74% (p = 0.001), respectively, after the study.ConclusionsOptimal algorithm adherence will be important for definitive PCT intervention trials in the US to determine if PCT guided algorithms result in better outcomes than reliance on traditional clinical variables. Factors influencing treatment decisions such as patient age, presence of fever, patient expectations and medical legal concerns may be amenable to education to improve PCT algorithm compliance for LRTI.

Procalcitonin-Guided Antibiotic Therapy Reduces Antibiotic Use for Lower Respiratory Tract Infections in a United States Medical Center: Results of a Clinical Trial

“…Provider attitude survey data from the Branche et al 26] study revealed that clinical signs of bacterial pneumonia drive the decision to continue antibiotics in patients with suspected LRTI. Similar findings were reported in the United States-based ProACT trial, where the adherence rate for pneumonia was 39% compared with 82% adherence in acute bronchitis [27], suggesting that provider belief about the presence of bacterial infection is difficult to modify with a PCT result.…”

Use of Procalcitonin and a Respiratory Polymerase Chain Reaction Panel to Reduce Antibiotic Use via an Electronic Medical Record Alert

“…A question of what factors caused providers to continue antibiotics is raised. In their follow-up analysis of their randomized trial, Branche and colleagues found that while several factors were mentioned by providers as reasons for deviation from their PCT de-escalation protocol including illness severity, fever, abnormal complete blood count, and others, only diagnosis of pneumonia was significantly associated with nonadherence [25]. An important distinction in this case is that viruses are able to cause radiographic changes [26][27][28].…”

Retrospective audit of antimicrobial prescribing practices for acute exacerbations of chronic obstructive pulmonary diseases in a large regional hospital

“…Despite the fact that patients were excluded if they have radiological evidence of pneumonia, sicker patients received ceftriaxone that is commonly used for pneumonia, albeit inappropriately in that indication as well . Clinicians' perceptions of a patient's severity of disease are noted as an important determinant of inappropriate prescribing . Higher CRP values and all the other clinical parameters in the absence of radiological evidence of pneumonia in COPD patients are classified as AECOPD, and therefore, these patients should not be receiving broad‐spectrum antibiotics like ceftriaxone as per the national guidelines.…”

“…16 Clinicians' perceptions of a patient's severity of disease are noted as an important determinant of inappropriate prescribing. 17 Higher CRP values and all the other clinical parameters in the absence of radiological evidence of pneumonia in COPD patients are classified as AECOPD, and therefore, these patients should not be receiving broad-spectrum antibiotics like ceftriaxone as per the national guidelines. Several studies have demonstrated that guideline concordant treatment of pneumonia has resulted in reduced in-hospital mortality, improved times to clinical stability and length of stay, [18][19][20] and has led many hospitals to implement bundles of care or flow charts in an attempt to improve guideline compliance.…”