Limitations
infectious disease
INFECTIOUS DISEASE, SYNDROMES
Our study has limitations worth discussing. First, we applied the resistance patterns of the population of urinary pathogens summarized in the antibiograms for determination of active and optimal empirical antibiotic therapy. We opted for this approach because our goal was to assess if use of either tool was associated with antibiotic choice. In actual practice, clinicians without a tool may have some sense of local resistance patterns based on experience alone, which may decrease the observed effect of using a tool on active choice. Second, the determination of optimal treatment was based on expert opinion of 3 antimicrobial stewardship and infectious disease experts, which introduces some subjectivity into the outcome of optimal antibiotic choice. Optimal therapy must first be an active antibiotic agent, which links these outcomes. Another analysis approach could focus on differences in broad-spectrum antibiotic therapy as defined by antibiotic classes rather than active and optimal treatment. Furthermore, our methods assume that the case patients’ clinical presentations and urine pathogens do not vary significantly from the patient population and urine pathogens used to develop the antibiogram tools.We chose to first test these tools in a simulated setting as it allows for a fairly quick evaluation of the antibiograms that can be distributed widely using web-based platforms to busy clinicians. Although we requested respondents to answer as they would practice in real-life, our findings have limited generalizability to real practice. Additionally, our convenience sampling method prevents the determination of a response rate, and it may allow for selection bias, limiting the generalizability of our findings. Although this approach allowed for standardized evaluation of many different clinical scenarios, we focused on 4 common urinary tract syndromes. Additionally, our tools represent a single, fairly susceptible population of urine isolates—it is unclear if using a tool representing a different sample of urine isolates would result in both active and optimal antibiotic choices. Furthermore, we chose to embed the tools within the survey at the point of empirical antibiotic decision-making. In practice, antibiograms are typically available through intranet sites, pocket cards, or print outs and may not be readily used by clinicians in real life because of inaccessibility.