Specialist trainees on rotation cannot replace dedicated consultant clinicians for antimicrobial stewardship of specialty disciplines

Abstract

Our prospective-audit-and-feedback antimicrobial stewardship (AS) program for hematology and oncology inpatients was switched from one led by dedicated clinicians to a rotating team of infectious diseases trainees in order to provide learning opportunities and attempt a “de-escalation” of specialist input towards a more protocol-driven implementation. However, process indicators including the number of recommendations and recommendation acceptance rates fell significantly during the year, with accompanying increases in broad-spectrum antibiotic prescription. The trends were reversed only upon reverting to the original setup. Dedicated clinicians play a crucial role in AS programs involving immunocompromised patients. Structured training and adequate succession/contingency planning is critical for sustainability.

Impact of Regular Collaboration Between Infectious Diseases and Critical Care Practitioners on Antimicrobial Utilization and Patient Outcome*

“…Furthermore, we chose to analyze the effects of intervening daily rather weekly. Yeo et al (26) compared the effect an IDF versus a dedicated specialist on antimicrobial stewardship in a hematology and oncology ward. There are no studies to date that illustrate the beneficial effect an IDF can have on guideline compliance and antibiotic use in the MICU.…”

The impact of infectious disease specialists on antibiotic prescribing in hospitals

“…The trends were reversed only upon reversion to the original set‐up. Trainees' recommendations were sometimes suboptimal, and the weekly rotation of trainees resulted in conflicting recommendations to the primary teams on occasion, reducing their credibility . In another French study, ID trainees were often less well perceived than a senior IDS by the requesting physicians, particularly senior ones .…”

“…Compliance with IDS advice in practice by clinicians implies a positive perception of the usefulness of IDS advice. In the literature, compliance rates range from 35% to >90% . As compliance with IDS recommendations has been shown to be associated with improved patient outcomes , ensuring the best possible compliance is important.…”

“…However, in a French hospital where recommendations given by the ID resident were always supervised by a senior board‐certified IDS, advice was more frequently followed when it was given by the senior IDS . In a hospital in Singapore, a prospective‐audit‐and‐feedback AMSP for haematology and oncology inpatients was switched from one led by a dedicated senior IDS to one performed by a rotating team of four unsupervised ID trainees . The compliance rate fell significantly during the year, with an accompanying increase in antibiotic use.…”

Timeliness of Infectious Diseases Referral and Inappropriate Antibiotic Usage Post-Referral in an Asian Tertiary Hospital

“…Given that early antibiotic administration is associated with higher survival rates in the context of febrile neutropenia [17] and that having a haematological or oncological condition is associated with high risk of subsequent clinical deterioration and unplanned readmission [7,18], early ID specialist referral should be a part of efforts to ensure that this group of patients receives early and appropriate antibiotic therapy [19]. In local studies evaluating acceptance of ASP recommendations for haematology/oncology patients, acceptance was more likely when the recommendations were made by dedicated ID specialists, rather than a rotating team of specialists or by trainee ID physicians [20], suggesting that early ID specialist referral for haematology/oncology patients could potentially be fostered by building close relationships between haematology/oncology primary physicians and a team of dedicated haematology/oncology ID specialists.…”