Resident Physician Prescribing Variability Demonstrates Need for Antimicrobial Stewardship in Continuity Clinic: A Pilot Study

Background: Inappropriate antimicrobial use is common in the outpatient setting but often goes unaddressed by stewardship education. Residents might benefit from directed stewardship education. Objective: We conducted a needs assessment of resident knowledge, attitudes, and behaviors regarding antibiotic use and stewardship in outpatient continuity clinics. Methods: Internal medicine (IM) residents with continuity clinic at Minneapolis Veterans Affairs Health Care System were eligible. Antimicrobial prescriptions and number of visits were extracted from the Computerized Patient Record System (July 1, 2017-March 31, 2018). Antimicrobial rate (prescriptions per 1000 visits) was calculated for each resident. Results from a resident survey that included demographics, attitudes, and case-based multiple-choice knowledge questions were linked by unique identifier to antimicrobial rate. Results: Prescription and visit data were available for 37 residents. Mean monthly antimicrobial rate was 51 prescriptions per 1000 visits (range 8-239). Surveys were completed by 19 residents (51%). Respondents were 32% female, 32% interns, and 11% international medical graduates. An online resource was most commonly used for prescribing guidance, whereas lectures and small group sessions for residents were rated as the most helpful educational modalities. Many respondents reported being unprepared to perform basic tasks related to antimicrobial stewardship. Median percentage correct was 57% of case-based knowledge questions (interquartile range 50%-71%). Conclusions: Antimicrobial rates among IM residents at a VA outpatient continuity clinic are low and vary by provider. Residents agree with key antimicrobial stewardship concepts but lack preparation in tasks related to antimicrobial stewardship. Knowledge regarding antimicrobial prescribing was low.