The association of patient complexities with antibiotic ordering

BACKGROUND: Antibiotic treatment decisions for medically complex patients are complicated, as the risk of undertreatment may be severe, whereas overtreatment may be associated with adverse effects and the emergence of antibiotic resistant pathogens. OBJECTIVE: To determine the influence of patient complexities on providers' decisions to prescribe antibiotics in 3 common hospital-based clinical vignettes. DESIGN: A physician survey. SETTING: Three urban medical centers in Los Angeles County, California. PARTICIPANTS: Hospital-based physicians. MEASUREMENTS: Physicians were presented 3 clinical vignettes, with variations by patient age, comorbidity burden, functional status, and follow-up, and asked to choose the best antibiotic regimen. We described the association of additional patient complexity on the proportion of guideline-adherent antibiotic choices. RESULTS: In the survey, 28% to 49% of physicians recommended antibiotics that were inconsistent with national guidelines. This percentage increased to 48% to 63% for medically complex patients, defined as those with either older age, high medical comorbidity burden, poor functional status, or limited follow-up after hospital discharge (P<0.01). CONCLUSIONS: In 3 vignettes depicting common clinical scenarios among hospitalized adults, inappropriate antibiotic use was prevalent and occurred more often for patients with medical complexities. Treatment guidelines should consider addressing medically complex patients in the context of infection management. Journal of Hospital Medicine 2015;10:446-452.