Antibiotics and sepsis: the art and science of polarity management

With thanks to Jim Mather of the University of Stirling for introducing me to Polarity Management by Barry Johnson.

Some things in life require choices between different options. These may be complex, but once made, the world generally moves on

• should I apply for this job?
• should I choose this school for my children?
• should I start a beta-blocker to reduce blood pressure in this patient?

But there are other things which do not lend themselves to this sort of decision making. There exists on ongoing tension between polarities.

• should I spend more time doing clinical work/more time in a leadership role
• my children should be independent / we should do more as a family
• we should use antibiotics earlier in infections to stop serious consequences/we should hold back on antibiotics to prevent resistance and other problems of over treatment

These problems don't lend themselves to simple decisions. Rather they are ongoing tensions to be managed continuously. This is, unfortunately, not what tends to happen. What we see are people endlessly embroiled in attempting to solve problems at one end of the polarity or the other. How can I reduce antibiotic resistance? How can I improve the time to antibiotics in patients with suspected sepsis? And in doing so tending to lose sight of the opposite polarity. This often leads to entrenchment in negative positions, and disharmony between those with opposing world views. Alternatively, we see short term shifts towards one pole, and then lurches back the other way. Tension becomes unproductive swings in approach.

This does seem to be what is happening with the sepsis / antibiotic stewardship agendas at the moment. A few years ago, antibiotic stewardship dominated the agenda, thanks mainly to the rise of C. difficile. This has contributed to the huge successes in reducing incidence of this condition over recent years. But there has always been the potential for a backlash to this approach, with clinicians feeling constrained in their ability to prescribe what they want.

More recently, there has been a strong push to improve management of sepsis. Most hospitals will have set up teams to study sepsis. They report back that we need to give antibiotics earlier. "Yes, we think antibiotic stewardship is important, but what is really important when we think about sepsis is giving antibiotics quickly." Antibiotic stewardship is seen as a worthy thing, but not actually relevant to the patient I have got in front of me.

We can see the same tensions when we consider this problem from the perspective of the patient. On the one hand, I want to get better from whatever it is that is making me ill, be that a sore throat or life threatening sepsis. If an antibiotic makes me get better 24 hours earlier, or saves my life, that seems like a good thing. On the other hand, I am being told that using antibiotics could make future infection harder to treat, may have side effects, and may even cause problems through their effects on 'good' bacteria.

Polarity management I think has something to teach us about how we approach these problems. They can never be solved. Clinical decisions regarding antibiotics (or anything really) are rarely clear cut. Rather they exist in this tension between doing things now, and doing things a bit later (or not at all). Polarity management takes us through a few steps that are perhaps useful in managing this tension.

First we define four quadrants. On the left we have "Now", and on the right we have "Later". At the top we have positives, at the bottom we have negatives. It is usually pretty easy to fill these in. So for example, for antibiotics we might have :

Benefits of early treatment Get better quickly Prevent complications Early discharge Clinician engagement with prescribing decisions	Benefits of delayed treatment Reduce antibiotic usage Protect 'good' bacteria Reduce C difficile rates More standardisation of infection management
Harms of early treatment Overtreat More C difficile More resistance More collateral damage 'Random' approaches to antibiotic prescribing	Harms of delayed treatment Undertreat Delayed recovery More complications More serious infections Less clinician engagement

So what we often see happening in systems that have become focussed on a polarity is that people who see the opposite polarity in a particularly positive light start to identify with the negative dominant quadrant (so the 'antibiotic steward' sees the overtreatment of infection leading to antibiotic resistance). There is an increasing clamour for change. The harms of the current approach become self evident, and the system then shifts (more control on antibiotic use). Setting the cycle in train again from the other perspective (delayed treatment and clinician disengagement). Or, alternatively, it doesn't shift, and people become increasingly entrenched in their negative views of the world.

What polarity management does is really very simple, and I think has 2 main effects. First, by making the upsides and downsides of poles explicit, everyone can see that there are tensions that need to be managed. But they know that their voice is being heard. And second, there is now a route map that people can be taken on to explore the two poles. Rather than become boxed into a corner, they can be taken on a journey to the other side of the spectrum. What often works is to start off in the negative quadrant of the pole with which you most identify (eg. too many antibiotics being used). Of course, it is then very easy to think of all the upsides that counter these (moving to the upper quadrant. eg. early treatment of sepsis). Now you ask people to think about the negative things that the alternative approach would have (opposing quadrant. eg. delayed infection management). Again, this is pretty easy for them to do - this is, after all, why they like their approach. But finally you ask them to think about the final positive quadrant (eg. more standardised approaches). Because they feel safe - their voice has been heard - this is not now a dangerous place for them to be.

What happens when we do this for sepsis? I think we end up in a different place. It becomes easier to see the world from multiple perspectives, but, perhaps most importantly, we start thinking about individual patients a bit more. What are timely antibiotics in a patient with a rather undifferentiated presentation which might be due to infection? What are the most appropriate antibiotics to use in someone with a crackles on their chest and a fever, but a normal chest X-ray? And we start thinking perhaps a bit more clearly about how we can probably never resolve these into right and wrong answers, but become a bit more sophisticated in managing and enjoying the tensions inherent in complex medicine.