Antibiotic practice patterns with procalcitonin levels in patients with acute lower respiratory tract infection.

OBJECTIVES: Procalcitonin (PCT) testing is FDA approved to guide antibiotic therapy in patients with lower respiratory tract infection (LRTI). However, its utilization and impact on real-world antibiotic prescribing behavior are unknown. We investigated the rate of PCT testing to evaluate an association between initial PCT level and antibiotic prescription patterns for patients with suspected LRTI within a large integrated health system. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective cohort study (January 1, 2016, through December 31, 2017) was performed in patients 18 years and older who were hospitalized with LRTI and had a PCT measurement. Antibiotic changes were noted before and 36 hours after initial PCT results. Antibiotic concordance was determined using a PCT cutoff value of 0.25 mcg/L. Concordance was defined as (1) patients received antibiotics after a PCT of at least 0.25 mcg/L resulted or (2) antibiotics were withheld after a PCT less than 0.25 mcg/L resulted. RESULTS: PCT testing occurred in 18% of hospitalized patients with LRTI. Among 1606 patients, antibiotic concordance with PCT results was 55%. Among the discordant population, 77% of patients received antibiotics in the setting of a low PCT level compared with 23% who did not receive antibiotics at a high PCT level. There were no statistical differences between LRTI types between patients with PCT-discordant and PCT-concordant care. CONCLUSIONS: Within a real-world environment of patients hospitalized with LRTI, PCT testing was low and the PCT levels did not appear to influence antibiotic prescribing behavior. Our findings suggest that clinicians continue to prioritize clinical judgment over initial PCT levels when prescribing antibiotics for suspected LRTIs.

Resident and Faculty Perspectives on Prevention of Resident Burnout: A Focus Group Study.

CONTEXT: The high prevalence and negative implications of resident physicians' burnout is well documented, yet few effective interventions have been identified. OBJECTIVE: To document resident and faculty perspectives on resident burnout, including perceived contributing factors and their recommended strategies for attention and prevention. DESIGN: We conducted 14 focus groups with core faculty and residents in 5 specialties at a large integrated health care system in Southern California. Training programs sampled included family medicine, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry. Discussions were recorded, transcribed, and analyzed using a matrix-based approach to identify common themes. MAIN OUTCOME MEASURES: Resident and faculty perspectives regarding causes of burnout, preventive factors, and potential intervention strategies. RESULTS: Five themes captured the range of factors participants identified as contributing or protective factors for resident burnout: 1) having or lacking a sense of meaning at work; 2) fatigue and exhaustion; 3) cultural norms in medicine; 4) the steep learning curve from medical school to residency; and 5) social relationships at and outside work. Recommended intervention strategies targeted individuals, residents' social networks, and the learning and work environment. CONCLUSION: We engaged residents and core faculty across specialties in the identification of factors contributing to burnout and possible targets for interventions. Our results highlight potential focus areas for future burnout interventions and point to the importance of interventions targeted at the social environments in which residents' work and learn.