Prescriber perceptions of fluoroquinolones, extended-spectrum cephalosporins, and Clostridioides difficile infection

Abstract

Background: Fluoroquinolones (FQs) and extended-spectrum cephalosporins (ESCs) are associated with higher risk of Clostridioides difficile infection (CDI). Decreasing the unnecessary use of FQs and ESCs is a goal of antimicrobial stewardship. Understanding how prescribers perceive the risks and benefits of FQs and ESCs is needed. Methods: We conducted interviews with clinicians from 4 hospitals. Interviews elicited respondent perceptions about the risk of ESCs, FQs, and CDI. Interviews were audio recorded, transcribed, and analyzed using a flexible coding approach. Results: Interviews were conducted with 64 respondents (38 physicians, 7 nurses, 6 advance practice providers, and 13 pharmacists). ESCs and FQs were perceived to have many benefits, including infrequent dosing, breadth of coverage, and greater patient adherence after hospital discharge. Prescribers stated that it was easy to make decisions about these drugs, so they were especially appealing to use in the context of time pressures. They described having difficulty discontinuing these drugs when prescribed by others due to inertia and fear. Prescribers were skeptical about targeting specific drugs as a stewardship approach and felt that the risk of a negative outcome from under treatment of a suspected bacterial infection was a higher priority than the prevention of CDI. Conclusions: Prescribers in this study perceived many advantages to using ESCs and FQs, especially under conditions of time pressure and uncertainty. In making decisions about these drugs, prescribers balance risk and benefit, and they believed that the risk of CDI was acceptable in compared with the risk of undertreatment.

Behavioral change challenges in limiting fluoroquinolone and extended-spectrum cephalosporins to prevent Clostridioides difficile disease

“…However, for any strategy to work, data need to be robust regarding the reason that the stewardship intervention is indicated, and messaging needs to be clear on how the intervention will improve patient outcomes. The work by Szymczak et al 6 suggests that our work is not finsihed in either regard.…”

“…With these efforts in mind, Szymczak et al 6 sought to determine behavioral barriers to limiting the use of fluoroquinolones and extended-spectrum cephalosporins. Through interviews with 64 frontline clinicians and antimicrobial stewardship stakeholders at 4 hospitals in 2 university-based healthcare systems, these researchers were able to generate rich thematic content on the perceived benefits and risks of these agents, particularly when used for treatment of urinary tract infection and pneumonia.…”

Antimicrobial Use in a Cohort of US Nursing Homes, 2017

“…Use of broad-spectrum antibiotics may reflect the treatment of existing multidrug-resistant infections, which can be considerable in nursing homes, although inappropriate use can increase the risk for resistant infections and C. difficile infection . While some clinicians have stated a preference for prescribing broad-spectrum antibiotics because of their ease of use, including broad coverage, infrequent dosing, and patient adherence, some investigators have been able to reduce broad-spectrum antibiotic use in nursing homes through provision of education and access to alternative oral antibiotics for treatment of urinary tract infection . Due to the array of adverse events and high frequency of use, broad-spectrum agents should be prioritized for antimicrobial use surveillance and stewardship activities in nursing homes.…”

Deliver Us from Error: The Perils of Algorithmic Salvation in Medicine

“…In my work on antibiotic use, I emphasize that prescribing is a social act and a way for clinicians to communicate with their patients and colleagues (Szymczak and Newland 2018). An antibiotic prescription can accomplish more for a clinician than fixing pathophysiology-it can quell uncertainty or fear, reduce uncomfortable interactions, and increase work efficiency (Szymczak et al 2020. When stakeholders implement interventions to promote judicious prescribing that do not acknowledge what an antibiotic prescription accomplishes for clinicians in their everyday work, they run the risk of alienating their colleagues or encouraging workarounds that subvert the intention of the intervention, leading to waste and degraded professional relationships (LaRosa et al 2007;Szymczak et al 2014).…”