Payal Patel, MD, MPH

A few years ago, researchers in Israel decided to test the hypoth&shy;esis, “Justice is what the judge ate for breakfast.” More than 1000 parole decisions by 8 judges were reviewed and catego&shy;rized according to whether they happened at the beginning of the day, near a snack or meal, or at the end of the day.

 For each judge, the pattern held true: Prisoners were more likely to be granted parole after a snack or lunch break than just before a meal. The authors wrote that this indicated judicial rulings may be swayed by “extraneous” vari&shy;ables. There is evidence in health care, as well, that time of day, time of week, whether a national cardiology conference is happening, and many other extraneous factors can influence quality of care.

article by Sikkens and colleagues describes a single-center prospective study done with repeated point prevalence surveys to measure how factors such as gender, professional experience, and time of day (not all extraneous) can affect antimicrobial appropriateness.

 The investi&shy;gators performed 7 point-prevalence surveys in their 700-bed tertiary care hospital in Amsterdam. The study comprised 351 antimicrobial prescriptions by 150 physicians. The authors also mention that during the time this study was happening, there were no ongoing antimicro&shy;bial stewardship interventions, except pre-authorization for restricted antimicrobials and that pharmacists tend to have limited roles in anti&shy;microbial stewardship in Dutch hospitals.

The primary outcome was appropriateness of the antimicrobial prescription, which was defined as either following relevant guide&shy;lines, deviating from guidelines with a rational documented reason, or there was no relevant guideline, but the prescription was consid&shy;ered a rational choice. Appropriateness was determined by an adult or pediatric infectious diseases physician. The team found that, overall, appropriateness of antimicrobial prescriptions per the definition used in this study was 65% and that it was lower in the morning versus afternoon and night (43% vs 68% vs 70%, respectively; crude odds ratio [OR] afternoon vs morning, 3.00 [95% CI, 1.60-5.48]; crude OR evening vs morning, 3.40 [95% CI, 1.64-6.69]). They also found interns had less appropriate prescribing behavior versus more experienced colleagues and that an infectious disease consultation was associated with improved appropriateness. There was no difference in prescribing noted between the genders.

Although certainly an interesting paper, readers must take a few things into consideration when reflecting on this work. First, this is a single-center study and tells us only about this center. These results are not generalizable to other health care systems that may have different workflows, stewardship programs, ways of rounding, and culture. Second, defining appropriateness is tough and is one of the barriers to describing research in the antimicrobial stewardship field. The authors used a very broad interpretation of appropriateness here but did not note any inter-rater reliability, which decreases internal validity of the study. Third, factors that could influence prescriptions are countless and it would be difficult to make a reliable model for this work. However, the study was strengthened by a qualitative post hoc analysis that gave some potential reasons this “morning dip” in appropriateness may be seen at this hospital. Factors included the morning rush, reduced support from consultants, and lag time of diagnostic results in the morning.

One aspect of the study to take away is that it could be worth doing a similar study at your own center, particularly the combination of the quantitative and qualitative parts of this study to best target stewardship interventions. By doing that, one would be using several of the US Centers for Disease Control and Prevention core elements of hospital antibiotic stewardship programs (Tracking, Reporting, Action, and Education).

 If you see results like those found in this study, targeting stewardship interventions to the morning hours may have a greater impact than afternoons and nights. The authors also suggest that more education about stewardship could benefit housestaff. For now, this steward says avoid the morning dip by dipping into a coffee with an optional donut, and be mindful before you prescribe antibiotics.

Danziger S, Levav J, Avnaim-Pesso L. Extraneous factors in judicial decisions. 

. 2011;108(17):6889-6892. doi: 10.1073/pnas.1018033108.

Linder JA, Doctor JN, Friedberg MW, et al. Time of day and the decision to prescribe antibiotics. 

. 2014;174(12):2029-2031. doi: 10.1001/jamainternmed.2014.5225.

Mohammed MA, Sidhu KS, Rudge G, Stevens AJ. Weekend admission to hospital has a higher risk of death in the elective setting than in the emergency setting: a retrospective database study of national health service hospitals in England. 

. 2012;12:87. doi: 10.1186/1472-6963-12-87.

Jena AB, Prasad V, Goldman DP, Romley J. Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during dates of national cardiology meetings. 

. 2015;175(2):237-244. doi: 10.1001/jamainternmed.2014.6781.

Sikkens JJ, Gerritse SL, Peters EJG, Kramer MHH, van Agtmael MA. The 'morning dip' in antimicrobial appropriateness: circumstances determining appropriateness of antimicrobial prescribing. 

. 2018;73(6):1714-1720. doi: 10.1093/jac/dky070.

Pollack LA, Srinivasan A. Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. 

. 2014;59(suppl 3):S97-S100. doi: 10.1093/cid/ciu542.

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Targeting stewardship interventions to the morning hours may have a greater impact than afternoons and nights.

Payal Patel, MD, MPH

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