Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. In a retrospective analysis of a cohort of general internal medicine physicians, it was found that antimicrobial prescribing was 30% higher in the 4th quartile compared to the 1st quartile, indicating considerable variability in physician prescribing.

2. Variation in antimicrobial prescribing did not predict clinical outcomes after discharge, but in-hospital mortality was associated with higher intensity prescribing for antimicrobials.

Evidence Rating Level: 2 (Good)

The concept of antimicrobial stewardship among medical professionals is well-established, and preventing overuse is widely recognized as the most feasible way to prevent increasing levels of antimicrobial resistance on a global scale. However, physician-level variability in prescribing choices does bring with it the potential for long-term harms. The current retrospective cohort study of 124 physicians and 124,158 patient admissions evaluated these variations among patients admitted to general medicine wards in Toronto, Canada. Data spanning from 2010 to 2019 were extracted from four major Toronto hospitals via the General Medicine Inpatient Initiative (GEMINI), a highly reliable and accurate database. The primary measure used was days of therapy per 100 patient-days. The proportion of antimicrobial-free days was also calculated for each physician. The variability in the spectrum of prescribing was also assessed. The median physician percentage of antimicrobial-free days was 62.3%. The difference in mean prescribing between physicians in the 1st and 4th quartiles was 15.8 days of therapy per 100 patient-days. Median prescribing was 30% higher in the 4th quartile compared to the first. No significant differences were found for outpatient clinical outcomes when assessed based on physician quartiles of prescribing. Only in-hospital mortality was associated with the intensity of antimicrobials prescribed (OR 1.132, 95% CI 1.035–1.239). While there is naturally an acceptable amount of variation that exists in antimicrobial prescribing, the current study demonstrates that outcomes for patients did not improve for those clinicians in the highest quartiles for prescribing. This indicates that there is still an opportunity to improve stewardship without compromising patient outcomes. While limitations in data collection exist for this study, it is one of the few that has assessed physician variability in antimicrobial prescribing in general medicine wards.

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