Doctors favor personalized care over IDSA guidelines

Many doctors prefer the treatment approach for Lyme disease espoused by the International Lyme and Associated Diseases Society (ILADS), which recommends personalized care relying on clinical judgment when fixed antibiotic regimens fail. [1] That is in contrast with the guidelines put forth by the Infectious Diseases Society of America (IDSA), which calls for fixed antibiotic therapy of no more than 4 weeks unless the patient is presenting with Lyme arthritis. [2]

by Daniel J. Cameron, MD MPH

A recent study in the Journal of Hospital Medicine examines doctors’ knowledge and acceptance of antibiotic-prescribing guidelines for 3 common illnesses: a skin and soft tissue infection, suspected hospital-acquired pneumonia (HAP), and asymptomatic bacteriuria (ASB). [3]

IDSA recommendations for treating such conditions were given to 30 hospital staff physicians, who “were asked to discuss their level of comfort with following these guidelines,” according to Livorsi and colleagues from the Division of Infectious Diseases, University of Iowa Carver College of Medicine. [3]

The authors describe “the tension between adhering to guidelines and individualizing patient care.”

“Although participants agreed with guidelines in principle, they had difficulty applying specific guideline recommendations to an individual patient’s care.”

Participants acknowledged that there are limitations with clinical guidelines. They pointed to cases in which following guidelines would not be in the patient’s best interest and that “specific patient populations” have not been well-studied. These cases, according to many participants, require “independent decision-making.”

Doctors are torn over following treatment guidelines and using personalized care and clinical judgment.

Following are some of the comments made by doctors participating in the study:

• “Guidelines are guidelines, but at the end of the day, it still comes down to individualizing patient care, and so sometimes those guidelines do not cover all the bases, and you still need to do what you think is best for the patient.”

• “The guidelines are not examining the patient, and I am examining the patient. So I will do what the guidelines say unless I feel that that patient needs more care.”

• “To me, the guidelines are adding a little bit more of a stress, because the guidelines are good for the more obvious things; they’re more black and white, this than that. But clinical medicine is never like that. There is always something that makes it really gray, and some of it has to do with things that you’re seeing because you’re there with the patient that doesn’t quite fit.”

The authors also found, “Both residents and attending physicians expressed skepticism about the evidence behind some guideline-recommendations or admitted that they did not agree with the recommendations.” [3]

In one scenario, a majority of the participants said they felt uncomfortable following guidelines which recommended stopping antibiotics for HAP if a patient had clinically improved and if a lower-respiratory tract culture was negative.

The doctors’ responses to guidelines for the 3 common illnesses discussed echo similar responses to the IDSA guidelines for tick-borne illnesses.

Editor’s note: Dr. Cameron is first author of the ILADS guidelines which favor using personalized medicine in the treatment of tick-borne diseases.

References:

1. Cameron DJ, Johnson LB, Maloney EL. Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. Expert Rev Anti Infect Ther. 2014:1-33.
2. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43(9):1089-1134.
3. Livorsi D, Comer AR, Matthias MS, Perencevich EN, Bair MJ. Barriers to guideline-concordant antibiotic use among inpatient physicians: A case vignette qualitative study. J Hosp Med. 2016;11(3):174-180.