Feeling the Vibes: An Investigation Into Resident Antibiotic Prescribing Practices

Background: Efforts to improve inpatient antibiotic prescribing are limited by a lack of insight into the complicated decisions around antibiotic use. We aimed to explore antibiotic therapeutic decision making among internal medicine resident physicians. Methods: We performed a qualitative study with a constructivist paradigm employing semistructured in-person focus groups of internal medicine trainees at a teaching hospital system from December 2023 through January 2024. Two researchers independently performed a thematic analysis of focus group transcripts. We resolved discrepancies through in-depth discussion, negotiated consensus, and converged codes into overarching themes. Results: Twenty-five residents participated across 3 focus groups. Residents identified a general approach to prescribing empiric antibiotics, including triaging critical illness and identifying the presence of infection, the source of infection, the antibiotic that covers the likely pathogens, and relevant patient-specific factors. Empiric choice was modulated by 3 subthemes: institutional culture, antibiotic stewardship policies, and clinical resources. Major challenges in therapeutic decision making included navigating uncertainty, fear of clinical deterioration, difficulty determining appropriate antibiotic duration/spectrum, and the inconsistency of clinical reasoning by supervising attendings. Certain safety net strategies were used to mitigate this uncertainty. Residents felt that their confidence in antibiotic prescribing decisions improved over time through experience, especially on overnight rotations. Infectious diseases physicians and pharmacists provided education and a needed model approach for therapeutic reasoning and supported residents in increasing their risk tolerance. Conclusions: This study provides insights into resident decision making regarding antibiotic use, which may inform educational interventions to optimize antibiotic utilization and adherence to practice guidelines at teaching hospitals.