JAC Advance Access originally published online on March 13, 2006
Journal of Antimicrobial Chemotherapy 2006 57(5):963-965; doi:10.1093/jac/dkl042
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Antimicrobial practice |
Knowledge about sepsis among training-grade doctors
Department of Infection and Immunodeficiency, Ninewells Hospital and Medical School, Dundee DD1 9SY, Scotland, UK
* Corresponding author. Fax: +44-709-2022650; E-mail: hziglam{at}doctors.org.uk
Received 30 September 2005; revised 11 November 2005; revised and accepted 30 January 2006
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Abstract |
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Background: Prescribing of antibiotics, often in the empirical setting, frequently falls on training-grade or junior doctors, who are often the least experienced in this. Indeed, improving the knowledge base of training-grade doctors or senior medical students through education has been identified as one of the key measures to improve antibiotic prescribing behaviour.
Methodology: We undertook two descriptive questionnaire- and interview-based surveys (1999 and 2003) of prescribing training-grade doctors in a teaching hospital in north-east Scotland to determine their knowledge level regarding various sepsis definitions, sources of local information used when prescribing an antimicrobial, and awareness of the cost difference between intravenous and oral antibiotics. A total of 55 junior doctors in a large teaching hospital participated in the survey in 1999 and 78 participated in 2003.
Interventions: Between the two audits, which were conducted 4 years apart, several initiatives were introduced to improve the education and support related to antibiotic prescription.
Results: There has been a significant improvement in doctors' knowledge regarding various sepsis definitions, whether the infection was hospital or community acquired, empirical choice, dose, route of administration and monitoring of the antibiotic, and options for drug hypersensitivity. More training-grade doctors (
29%) used the desired locally derived sepsis protocol, which guides the prescriber through sepsis recognition. There was no significant improvement in the percentage of doctors who recognized that parenteral antimicrobials were more expensive (10-fold) than oral antimicrobials (63.7% in 1999, 64.2% in 2003).
Conclusions: Overall, there was a significant improvement in doctors' understanding of sepsis and knowledge of the source of information that they utilized to select the antibiotic of choice, although the majority did not acknowledge the price difference between intravenous and oral forms of antibiotics.
Keywords: SIRS , antibiotic prescription , junior doctors , antibiotic cost
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Introduction |
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Sepsis is recognized by clinicians as an important cause of mortality in the intensive care setting.1 Recognition of a patient with sepsis is one of the key components of the clinical decision-making process when considering prescription of an antibiotic.
In August 1991, a North American Consensus Conference agreed on a set of definitions that could be applied to patients with sepsis and its sequelae.2 These definitions are generally well known to clinicians working in the critical care setting, but knowledge of them among general physicians and other specialists is fragmented.1 Indeed, in this important survey, only 17% of physicians agreed on any one definition for sepsis, and six different definitions were mentioned by at least 1 in 10 physicians.1 This lack of clarity about definitions may contribute to delay in diagnosis and early treatment. Our experience from providing our hospital with an infection consultation service for bacteraemia and sepsis confirms these findings and perceptions,3 and this remains a cause for concern. Knowledge improvement, with the aim of changing attitude and ultimately behaviour,4 has been identified as a key goal for promoting good practice. We undertook a prospective assessment of the current level of understanding among prescribing staff as a means of identifying their educational needs. The questionnaire was designed to reveal the doctors' understanding of the definitions of sepsis and its sequelae, sources of local information used when prescribing an antimicrobial, criteria utilized when deciding on the route of administration of an antimicrobial and when switching from the intravenous (iv) to the oral route, and awareness of the cost difference (10-fold) between iv co-amoxiclav and oral therapy.
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Methods and results |
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TopAbstractIntroductionMethods and resultsDiscussionTransparency declarationsReferences |
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We undertook two descriptive questionnaire- and interview-based surveys (1999 and 2003) of prescribing training-grade doctors in Ninewells Hospital and Medical School in Dundee, Scotland. Fifty-five junior doctors participated in the survey in 1999 and 78 in 2003 (Table 1). The clinicians interviewed included training-grade doctors working in general medicine and in general surgery and those on a vocational general practice rotation. Each clinician interviewed was asked to consent to the interview and no identifying characteristics were recorded except age, specialty and years since qualification. We asked the interviewee not to consult any information regarding infection/sepsis prior to the interview. Between 1999 and 2003 the availability of protocols, microbiology and ID advice was unchanged but there was a more active implementation of a sepsis teaching programme to junior training-grade doctors within the hospital. The surveys aimed to collect information related to the parameters identified above.
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We compared the key information gathered in the two years and the data are presented in Table 1. The data and results for this study are presented as percentages (Table 1). Data were analysed using Student's t-test. P < 0.05 was considered statistically significant.
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Discussion |
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The relatively small study sample, uncontrolled nature of the observations and two different groups of clinicians being interviewed at separate times were some significant study limitations. Although this precludes any major conclusions being drawn from this study, there are a number of observations that provide some useful information when planning future educational and protocol implementation strategies. Furthermore, very little information exists in the literature around the knowledge base and clinical decision-making processes of a broad body of non-infection-specialist training-grade clinicians for infection management.
These data shed some light on the distinct lack of clarity and consistency about sepsis definitions among these doctors. Despite an improvement in 2003 it is worrying that only 48 and 67%, respectively, could define severe sepsis and shock correctly (Table 1). This deficiency could clearly compromise the ability of the doctor to deliver the appropriate antibiotic and supportive therapy. We believe that we have identified a significant training need in a non-infection-specialist workforce of doctors who are unlikely to have sepsis management and antimicrobial prescribing as a key part of their training curriculum.
The other important finding of this study was that not all doctors used local support for antimicrobial prescription and that those who did varied in the resource that they used. The British National Formulary appeared to be the least used resource. We do not know whether this variation reflected the actual practice of the doctor or reflected what the doctor believed the interviewer might wish to hear.
The fact that 65% did not recognize that parenteral antimicrobials were significantly (10-fold) more expensive than oral antimicrobials is surprising and may indicate a general lack of consideration of cost or cost-effectiveness among training-grade doctors. This may contribute to excessive use of the iv route, particularly as in many units nurses will administer parenteral agents or junior staff will be reluctant to change to oral therapy before the next consultant ward round or at weekends.
To conclude, this study highlights, among training-grade staff, a lack of clarity and consistency in defining sepsis and its sequelae. There is also a marked variation in use of prescribing support and sub-optimal consideration of cost issues related to the route of antibiotic administration. We would urge a more thorough review in other centres. This deficiency in the knowledge base clearly requires targeted training and has stimulated a local and national drive to improve undergraduate5 and post-graduate education6 by introducing core antimicrobial prescribing competencies into the curricula of all doctors in training and other prescribers.
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Transparency declarations |
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None to declare.
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Acknowledgements |
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We would like to thank Dr S. Moitra who was significantly involved in collecting data during 1999. Unfortunately we were unable to include Dr Moitra in the author list as we could not contact her to obtain her signed consent.
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References |
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1. Poeze M, Ramsay G, Gerlach H et al. An international sepsis survey: a study of doctors' knowledge and perception about sepsis. Crit Care 2004; 8: R409–13.[CrossRef][Medline]
2.
Bone RC, Balk RA, Cerra FB et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 1992; 101: 1644–55.
3.
Nathwani D, Davey P, France AJ et al. Impact of an infection consultation service for bacteraemia on clinical management and use of resources. QJM 1996; 89: 789–97.
4.
Cabana MD, Rand CS, Powe NR et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282: 1458–65.
5.
Davenport LA, Davey PG, Ker JS. An outcome-based approach for teaching prudent antimicrobial prescribing to undergraduate medical students: report of a working party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2005; 56: 196–203.
6. Scottish Executive Health Department Antimicrobial Prescribing Policy and Practice in Scotland. Recommendations for good antimicrobial prescribing in acute hospitals. http://www.show.scot.nhs.uk/sehd/cmo/CMO(2005)8report.pdf. Edinburgh, 2005.
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