Author(s):
Christopher Guidry; Aubrey Swilling; Jacob O’Dell; Robel Beyene; Christopher Watson; Robert Sawyer

Background:

The practice of rapidly initiating antibiotics for patients with suspected infection has recently been criticized yet remains commonplace. Provider comfort level has been an understudied aspect of this practice.

Hypothesis:

We hypothesized that there would be no significant differences in provider comfort level between the two treatment groups.

Methods:

We prospectively surveyed critical care intensivists who provided care for patients enrolled in the Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP), which was a multicenter cluster-randomized crossover trial that evaluated an immediate antibiotic initiation protocol compared with a protocol of specimen-initiated antibiotic initiation in ventilated patients with suspected new-onset pneumonia.  In the specimen-initiated arm, for patients without shock, antibiotics were withheld until there was objective evidence of infection, usually a positive Gram stain. At the end of each enrollment arm, physicians at each center were surveyed regarding their overall comfort level with the recently completed treatment arm, and perception of adherence.  Providers completing the specimen-initiated arm were further queried regarding clinical changes that would urge then to initiate antibiotics without waiting for objective evidence.

Results:

We collected 51 survey responses from 31 unique participants.  Most respondents had been in practice for 10 years or less (0-5 years: 38.7%, 6-10 years: 25.8%).  Providers perceived a higher rate of adherence to the immediate initiation arm than the specimen-initiated arm (Always Adherent: 37.5% vs. 11.1%; p=0.045). Providers were less comfortable waiting for objective evidence of infection in the specimen-initiated arm than with starting antibiotics immediately (Very Comfortable: 83.3% vs. 40.7%; p=0.004). Providers listed a worsening PaO2/FiO2 ratio (63%), Bronchoscopy findings (40.7%) and a rising WBC (29.3%) as the most common reasons why antibiotics might be started before return of microbiological evidence of pneumonia. 100% of respondents stated they would participate in a similar study in the future.

Conclusions:

There are significant differences in provider comfort levels and perceptions of adherence when considering two different antibiotic initiation strategies for suspected pneumonia in ventilated patients. These findings should be considered when planning future studies.