McCreary, Erin K

ABSTRACT Beta‐lactam antibiotics (beta‐lactams) are first‐line treatments for most major infectious syndromes in acutely ill patients, with in vitro activity against common pathogens, demonstrated efficacy in trials, and a perceived low risk of adverse effects. The current dosing approach, informed by population‐level data, tends to be simplistically reduced to a “one size fits all” dosing method which only accounts for body weight (i.e., in pediatrics) and end organ function to estimate drug clearance (e.g., estimated glomerular filtration rate); this approach results in substantial variability in observed serum concentrations in acutely ill patients, which can compromise real‐world effectiveness and safety. Beta‐lactam dose individualization, therefore, defined as a dosing regimen for one patient informed by measured concentrations from that patient, has been recommended in international clinical guidelines. Comprehensive guidance on best practices for beta‐lactam dose individualization is lacking. To address this knowledge gap and develop guidance, a multidisciplinary panel of international experts was assembled from the disciplines of infectious diseases, critical care, pharmacometrics, and laboratory medicine, representing both adults and pediatrics. The panel systematically evaluated the literature, using the GRADE approach where feasible, to address broad thematic questions pertaining to whether beta‐lactam dose individualization should be pursued, for what indications beta‐lactam dose individualization is warranted, and the most critical considerations and best practices for implementation of beta‐lactam individualization. The resultant consensus recommendations will equip healthcare professionals caring for acutely ill patients treated with beta‐lactam therapy with the evidence and tools necessary to guide optimal use of beta‐lactam dose individualization.

AbstractIntroductionAlthough letters of reference (LORs) are required for postgraduate year one (PGY1) residency applications and used to distinguish between candidates, an evaluation of residency program director (RPD) perceptions and values surrounding LORs has not been described.ObjectiveThe aim of the study was to describe PGY1 RPDs' processes, values, and perceptions surrounding LORs.MethodsThis was a cross‐sectional descriptive survey. After assessing content validity, the Education and Training Practice and Research Network (PRN) taskforce sent a 25‐item electronic survey to 1266 PGY1 RPDs. Survey questions captured program demographics, LOR requirements, processes for LOR review, and perceptions about the value of LORs. Two open‐ended questions solicited suggestions for LORs and the existing standardized form; responses were evaluated via thematic analysis.ResultsA total of 291 (24%) programs completed the survey. LORs were rated as extremely or quite valuable by 82% of respondents and moderately valuable by 16% of respondents. Scoring rubrics for LOR evaluation were used by 79% of programs, and performance ratings were reported to impact interview consideration by a majority of programs. Accuracy, detailed comments, and inclusion of specific candidate strengths and areas for improvement were rated as extremely or quite important characteristics by 90% or more of respondents. Specific strengths were reported to be present in LORs more than half of the time by 81% of programs; however, accuracy, detailed comments, and inclusion of specific areas for improvement were only reported to be present about half the time or less by 41%, 63%, and 63% of respondents. Among 207 suggestions submitted to improve LOR utility, common themes included a desire for LOR authors to have candid discussions with candidates prior to letter writing, to contextualize their relationship with the candidate, and provide honest and specific assessments.ConclusionLORs remain highly valued by PGY1 RPDs during application review. Several notable findings were observed, resulting in recommendations for LOR authors, residency applicants, and the standardized LOR form.