title: Provider Decisions to Treat Respiratory Illnesses with Antibiotics: Insights from a Randomized Controlled Trial.
abstract: BACKGROUND
  Lower respiratory tract illness (LRTI) frequently causes adult hospitalization and antibiotic overuse. Procalcitonin (PCT) treatment algorithms have been used successfully in Europe to safely reduce antibiotic use for LRTI but have not been adopted in the United States. We recently performed a feasibility study for a randomized clinical trial (RCT) of PCT and viral testing to guide therapy for non-pneumonic LRTI.
  
  
  OBJECTIVE
  The primary objective of the current study was to understand factors influencing PCT algorithm adherence during the RCT and evaluate factors influencing provider antibiotic prescribing practices for LRTI.
  
  
  METHODS
  From October 2013-April 2014, 300 patients hospitalized at a community teaching hospital with non-pneumonic LRTI were randomized to standard or PCT-guided care with viral PCR testing. Algorithm adherence data was collected and multivariate stepwise logistic regression of clinical variables used to model algorithm compliance. 134 providers were surveyed anonymously before and after the trial to assess knowledge of biomarkers and viral testing and antibiotic prescribing practices.
  
  
  RESULTS
  Diagnosis of pneumonia on admission was the only variable significantly associated with non-adherence [7% (adherence) vs. 26% (nonadherence), p = 0.01]. Surveys confirmed possible infiltrate on chest radiograph as important for provider decisions, as were severity of illness, positive sputum culture, abnormal CBC and fever. However, age, patient expectations and medical-legal concerns were also at least somewhat important to prescribing practices. Physician agreement with the importance of viral and PCT testing increased from 42% to 64% (p = 0.007) and 49% to 74% (p = 0.001), respectively, after the study.
  
  
  CONCLUSIONS
  Optimal algorithm adherence will be important for definitive PCT intervention trials in the US to determine if PCT guided algorithms result in better outcomes than reliance on traditional clinical variables. Factors influencing treatment decisions such as patient age, presence of fever, patient expectations and medical legal concerns may be amenable to education to improve PCT algorithm compliance for LRTI.
authors.affiliation: Department of Medicine, University of Rochester, Rochester, NY, United States of America.
authors.forename: Angela R
authors.initials: AR
authors.lastname: Branche
authors.affiliation: Department of Medicine, University of Rochester, Rochester, NY, United States of America.|Department of Medicine, Rochester General Hospital, Rochester, NY, United States of America.
authors.forename: Edward E
authors.initials: EE
authors.lastname: Walsh
authors.affiliation: Department of Medicine, Rochester General Hospital, Rochester, NY, United States of America.
authors.forename: Nagesh
authors.initials: N
authors.lastname: Jadhav
authors.affiliation: Department of Medicine, Rochester General Hospital, Rochester, NY, United States of America.
authors.forename: Rachel
authors.initials: R
authors.lastname: Karmally
authors.affiliation: Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States of America.
authors.forename: Andrea
authors.initials: A
authors.lastname: Baran
authors.affiliation: Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States of America.
authors.forename: Derick R
authors.initials: DR
authors.lastname: Peterson
authors.affiliation: Department of Medicine, University of Rochester, Rochester, NY, United States of America.|Department of Medicine, Rochester General Hospital, Rochester, NY, United States of America.
authors.forename: Ann R
authors.initials: AR
authors.lastname: Falsey
mesh_terms: D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002116:Calcitonin / Q000627:therapeutic use; D015740:Calcitonin Gene-Related Peptide; D000066491:Clinical Decision-Making; D005163:Factor Analysis, Statistical; D019983:Guideline Adherence; D019538:Health Care Surveys; D006282:Health Personnel; D006801:Humans; D010465:Perception; D010820:Physicians; D011498:Protein Precursors / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D012141:Respiratory Tract Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology*; D014481:United States / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents; C000606589:CALCA protein, human; D011498:Protein Precursors; D002116:Calcitonin; D015740:Calcitonin Gene-Related Peptide