WHY STOP? Quantifying Cognitive-Behavioural factors that influence the impact of PCR-POCT results on antibiotic cessation in ICU

Abstract

Abstract INTRODUCTION: Rapid Point of Care Tests for infection (POCT) do not consistently improve antibiotic stewardship (ASP) of suspected ICU infection. We measured 1) the effect of a negative PCR-POCT on antibiotic stop decisions, and 2) clinico-behavioural factors that prevent stopping.METHODS: Vignettes of antibiotic treated respiratory infection, with 4 distinct trajectories were presented to ICU clinicians: overall improvement, clinical improvement/biological worsening, clinical worsening/biological improvement, overall worsening. Initial and post PCR-POCT antibiotic decisions (stop or continue) /confidence levels were recorded. The PCR-POCT offer was voluntary but always presented and negative. Linear regression determined association of their final decision with influencing factors.RESULTS: Seventy clinicians responded. A negative PCR-POCT increased stop decisions in all scenarios (p<0.001) except improvement (already high); especially in discordant clin worse(49% pre-POCT vs 74% post-POCT). Inclination to stop was reduced by an ambiguous/worsening trajectory(p=0.015), initial confidence to continue(p<0.001), and involuntary receipt of POCT(p<0.001), not clinician experience or risk averseness. CONCLUSIONS: Negative PCR-POCT increases the inclination to stop antibiotics, particularly in ambiguous/worsening trajectories of ICU infection. Clinician intuition to continue and disinterest in POCT reduce its influence to stop. Highlighting and quantifying the predictive impact of behavioural-trajectorial factors can improve antibiotic stewardship and study design in ICU related infection.