Clinical Reasoning Behind Antibiotic Use in PICUs: A Qualitative Study

Area of Science:

• Pediatric critical care medicine
• Clinical reasoning
• Antibiotic stewardship

Background:

• Antibiotic use in pediatric intensive care units (PICUs) is common for suspected bacterial infections.
• Decision-making for antibiotic use in critically ill children is complex and multifactorial.
• Understanding the clinical reasoning of pediatric intensivists is crucial for optimizing antibiotic stewardship.

Purpose of the Study:

• To describe the clinical reasoning processes pediatric intensivists employ when making antibiotic-related decisions.
• To identify factors influencing antibiotic prescribing, including starting, stopping, and duration of treatment.
• To explore the interplay between analytical, intuitive, and safety-driven reasoning in pediatric antibiotic management.

Main Methods:

• A qualitative study using grounded theory was conducted in three Canadian tertiary PICUs.
• Data were collected through field observations during morning rounds and semistructured interviews with 21 PICU physicians.
• Thematic analysis was used to identify patterns in clinical reasoning and decision-making.

Main Results:

• Pediatric intensivists utilize an initial analytical approach to assess the likelihood of bacterial infection.
• When uncertainty persists, patient safety assessments and intuitive reasoning are employed, sometimes leading to expert consultation.
• Factors such as disease severity, consultant pressure, and continuation of prior antibiotic regimens can override initial clinical reasoning.

Conclusions:

• Pediatric intensivists employ diverse reasoning strategies to manage uncertainty in pediatric antibiotic decisions.
• Concerns for disease severity and patient safety can lead to antibiotic use that may not be fully supported by clinical evidence.
• The study identified several cognitive biases influencing antibiotic prescribing practices in critically ill children.