Infectious diseases

Respiratory and ID specialist turf war stalling antibiotic stewardship

A rift between respiratory physicians and infectious diseases specialists could be stalling efforts to fight the growing problem of antimicrobial resistance in patients with respiratory infections, researchers claim.

The study led by infectious disease specialist Associate Professor Jennifer Broome from the Sunshine Coast Clinical Unit in Queensland said the number of inappropriate prescriptions for respiratory conditions is considerably higher than for other diagnostic groups.

But in a series of interviews respiratory physicians have revealed just how fed up they are with antimicrobial stewardship (AMS) programs.

Doctors involved in the study criticised AMS for being ‘offensive’ and ‘undiplomatic’, while others had issues with having to seek approval from AMS teams before being able to prescribe certain antibiotics.

This led to an ‘us and them’ environment that made things difficult for junior doctors and nurses who felt ‘caught in the middle’.

According to the study published in the Journal of Hospital Infection, many respiratory physicians described receiving unsolicited AMS advice as an ‘invasion’ of clinical territory especially when it came to ‘basic’ respiratory conditions like COPD and CAP.

Several doctors also said the AMS role created conflict between respiratory and infectious diseases services because of different opinions on antibiotic choice, which led to confusion among junior staff and irritated senior staff.

A number of participants described feeling insulted when certain approval processes forced senior respiratory doctors to request antibiotic approval from a more junior AMS doctor.

“It’s offensive, it’s rude, it’s suggesting that we’re incompetent and that we have no expertise … it’s clearly an insult to our intelligence,” said one respiratory physician involved in the study.

“For ordinary pneumonic pathogens, pneumococcus, haemophilus, moraxella, chlamydophila, mycoplasma, legionella, I wouldn’t dream of getting assistance,” another respiratory physician said.

“I regard the management of those conditions as being our domain and they should ask advice from me … It’s very arrogant to say it [but] we’ve got to be arrogant about certain things.’

Meanwhile nurses participating in the study said they felt they were being positioned between the AMS team, pharmacists and the respiratory team in negotiating access to antibiotics that required approval.

For many this has led to fear of adverse clinical outcomes, risks to their reputations among the respiratory physicians and legal implications if they withheld antibiotics that were prescribed but not approved.

“You don’t want to compromise patient safety and if withholding that antibiotic, because it’s not approved, might compromise that safety, it’s not something I want to risk my registration for,” one nurse told an investigator.

While investigators say the findings, based on interviews with respiratory teams from two Australian hospitals, can’t be generalised to all programs across the board, they argued that unless AMS interventions consult with respiratory specialists there was little hope of tackling antimicrobial resistance in respiratory infections.

They added that antibiotic governance should be separated from infectious disease consultation advice and suggested that a broader solution would be for respiratory clinicians to drive AMS within their own clinical area of medicine.

“Perhaps the AMS challenge is to educate and inspire other services to enact change within their own specialties, rather than directly regulating or auditing their practice,” they wrote.

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