Research Letter | Medical Education

Infectious Disease Physician Availability and Postgraduate Antimicrobial
Stewardship Education in Japan
Toshiki Miwa, MD; Koh Okamoto, MD, MS, PhD; Yuji Nishizaki, MD, MPH, PhD; Yasuharu Tokuda, MD, MPH, PhD

Introduction+ Supplemental content

Given insufficient knowledge or unpreparedness regarding antimicrobial use among resident

Author affiliations and article information arelisted at the end of this article.

physicians,1-3

current postgraduate antimicrobial stewardship (AS) education may be insufficient.

Providing education is an important role of infectious disease (ID) physicians,4 but data regarding
their contribution to AS education among resident physicians are limited. We aimed to investigate
the association between ID physicians’ engagement in postgraduate education and resident
physicians’ perceptions and attitudes to elucidate the role of ID physicians as educators.

Table 1. Adjusted Odds Ratios (OR) of Institutional Factors Associated With Resident Physicians’ Perceptions and Attitudes Regarding Antimicrobial Stewardship(Multilevel Logistic Regression Analysis)aOR (95% CI)

Participants, No.

Presence of AS programs

Type of ID consultation
Medical record–review based
ID consultationb
Bedside ID consultationb

I agree that antimicrobials potentially do patients harm

3437

1.51 (1.27-1.81)c

0.81 (0.61-1.08)

I know when to use antimicrobials for asymptomatic bacteriuria

3410

1.42 (1.18-1.71)c

0.86 (0.63-1.16)

1.14 (0.86-1.51)

I know when to suspect Clostridioides difficile infection

3397

1.79 (1.48-2.17)c

0.62 (0.45-0.85)c

0.96 (0.71-1.30)

I can explain what AS is3396

1.88 (1.54-2.31)c

0.77 (0.56-1.07)

0.95 (0.70-1.29)

I am confident choosing appropriate antimicrobials

3403

1.28 (1.01-1.63)c

0.75 (0.50-1.13)

0.75 (0.51-1.11)

I know when I can choose oral antimicrobials

3385

1.57 (1.29-1.92)c

0.77 (0.56-1.06)

0.90 (0.67-1.22)

I know the need for antimicrobial de-escalation

3394

1.94 (1.60-2.36)c

0.76 (0.55-1.06)

0.98 (0.72-1.34)

3382

2.06 (1.71-2.47)c

0.73 (0.54-1.00)c

1.00 (0.74-1.33)

3431

1.65 (1.36-2.02)c

0.68 (0.49-0.95)c

1.06 (0.77-1.46)

3430

c

1.66 (1.39-1.99)

0.79 (0.59-1.06)

0.87 (0.66-1.15)

3426

1.62 (1.36-1.93)c

0.73 (0.55-0.97)c

0.91 (0.70-1.19)

3407

2.00 (1.63-2.47)c

0.74 (0.52-1.05)

1.18 (0.83-1.67)

3402

1.80 (1.50-2.16)c

0.85 (0.64-1.14)

0.85 (0.65-1.12)

3380

1.40 (1.17-1.67)c

0.86 (0.64-1.15)

1.08 (0.82-1.41)

3385

1.92 (1.60-2.34)c

0.77 (0.56-1.06)

1.18 (0.87-1.61)

3382

1,62 (1.36-1.93)c

0.77 (0.58-1.02)

1.13 (0.87-1.49)

Variable
Perceptions of AS and antimicrobial resistance

I know appropriate duration of therapy is determined in some
infections
Attitudes toward AS and antimicrobial resistance
I make sure if a patient has allergic history before
prescribing antimicrobials
I make sure if a patient is colonized with resistant pathogens
before prescribing antimicrobials
I make sure if a patient has antimicrobial exposure before
prescribing antimicrobials
I order culture tests when I suspect an infection whichneeds culturesI try to choose narrow-spectrum antimicrobials whenever possible
I try to choose oral antimicrobials rather than intravenous ones
whenever possible
I try to de-escalate antimicrobials when culture results are backI try to reduce the duration of therapy as recommended
in the guidelines
Abbreviations: AS, antimicrobial stewardship; ID, infectious diseases.

0.82 (0.62-1.09)

aThe model includes sex, postgraduate year, university or community hospital, presence of ID department at medical school, ID department rotation at medical school, AS education
at medical school, types of ID consultation during residency, resident physicians’ individual exposure to ID physicians during residency, the presence of opportunity for AS education
during residency, and the presence of AS programs.

bNo ID consultation was used as reference.

c

P < .05.
Open Access. This is an open access article distributed under the terms of the CC-BY License.

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JAMA Network Open | Medical EducationInfectious Disease Physician Availability and Postgraduate Antimicrobial Stewardship Education in JapanMethods
This cross-sectional study used a nationwide Japanese In-Training Examination platform for all
resident physicians regardless of their desired specialty in 2023.5 All participants who responded tothe additional survey were included in this study (eTable in Supplement 1). Univariable andmultivariable analyses were performed to assess the associations between resident physicians’
perceptions and attitudes toward antimicrobials and (1) the presence of ID consultation at aninstitutional level or (2) ID physicians’ education for resident physicians at an individual level.
Statistical tests were considered significant if the 2-tailed P-value was less than .05 and wereperformed using Stata version 16 (StataCorp) software (eMethods in Supplement 1). This study wasapproved by the institutional review board of the Japan Institute for Advancement of MedicalEducation Program and the University of Tokyo Hospital and followed the Strengthening theReporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. Data wereanalyzed in March 2023.

ResultsAmong 9011 resident physicians in 633 hospitals who participated in the examination, 4051 (45.0%)
from 577 hospitals responded to the survey. Of those, 1256 (31.0%) were female, 2092 (51.6%) werepostgraduate year (PGY)–1 physicians, 1959 (48.4%) were PGY-2 physicians, and the median (IQR)
age was 26 (26–27). Compared with those working in hospitals without an ID department,
respondents working in hospitals with bedside ID consultations were more likely to know theTable 2. Adjusted Odds Ratios (OR) of Individual Factors Associated With Resident Physicians’ Perceptions and Attitudes Regarding Antimicrobial Stewardship(Multilevel Logistic Regression Analysis)aOR (95% CI)
Variables

Participants, No.

Lectures onlyb

Feedback through ID
consultationb

ID department rotationb

Perceptions of AS and antimicrobial resistance
I agree that antimicrobials potentially do patients harm

3437

0.85 (0.63-1.15)

1.01 (0.75-1.36)

0.80 (0.58-1.10)

I know when to use antimicrobials for asymptomatic bacteriuria

3410

1.12 (0.82-1.52)

1.03 (0.76-1.40)

1.27 (0.92-1.75)

I know when to suspect Clostridioides difficile infection3397

0.81 (0.58-1.12)

1.31 (0.93-1.85)

0.88 (0.62-1.27)

I can explain what AS is3396

1.39 (1.00-1.94)c

1.49 (1.08-2.06)c

1.68 (1.19-2.37)c

I am confident choosing appropriate antimicrobials

3403

1.02 (0.66-1.55)

1.44 (0.96-2.16)

2.21 (1.46-3.36)c

I know when I can choose oral antimicrobials

3385

1.12 (0.81-1.55)

1.37 (1.00-1.88)

1.48 (1.06-2.06)c

I know the need for antimicrobial de-escalation

3394

0.86 (0.61-1.21)

1.06 (0.75-1.50)

0.87 (0.60-1.26)

I know appropriate duration of therapy is determined in some infections

3382

1.05 (0.76-1.44)

1.25 (0.90-1.73)

0.95 (0.67-1.35)

I make sure if a patient has allergic history before
prescribing antimicrobials

3431

0.89 (0.62-1.25)

0.79 (0.55-1.12)

0.82 (0.57-1.20)

I make sure if a patient is colonized with resistant pathogens before
prescribing antimicrobials

3430

1.08 (0.80-1.46)

1.36 (1.01-1.84)c

1.58 (1.15-2.19)c

I make sure if a patient has antimicrobial exposure before prescribing
antimicrobials

3426

0.79 (0.59-1.06)

1.25 (0.93-1.67)

1.20 (0.88-1.64)

I order culture tests when I suspect an infection which needs cultures

3407

0.78 (0.54-1.13)

0.92 (0.63-1.35)

0.73 (0.48-1.09)

I try to choose narrow-spectrum antimicrobials whenever possible

3402

0.96 (0.71-1.30)

1.42 (1.06-1.91)c

1.94 (1.42-2.66)c

I try to choose oral antimicrobials rather than intravenous ones
whenever possible

3380

0.86 (0.64-1.16)

1.10 (0.82-1.48)

1.16 (0.85-1.59)

I try to de-escalate antimicrobials when culture results are back

3385

0.72 (0.52-1.01)

1.03 (0.74-1.45)

0.81 (0.56-1.16)

I try to reduce the duration of therapy as recommended in the guidelines

3382

0.91 (0.68-1.23)

1.22 (0.91-1.65)

1.08 (0.79-1.49)

Attitudes toward AS and antimicrobial resistance

Abbreviations: AS, antimicrobial stewardship; ID, infectious diseases.
aThe model includes sex, postgraduate year, university or community hospital, presence of ID department at medical school, ID department rotation at medical school, AS education
at medical school, types of ID consultation during residency, resident physicians’ individual exposure to ID physicians during residency, the presence of opportunity for AS education
during residency, and the presence of AS programs.

b

No education was used as reference.

c

P < 0.05.
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JAMA Network Open | Medical Education

Infectious Disease Physician Availability and Postgraduate Antimicrobial Stewardship Education in Japan

concepts of AS (641 of 1558 [41.1%] vs 532 of 1770 [30.1%]; odds ratio [OR], 1.63; 95% CI, 1.41-1.88;
P < .001) and more likely to be confident in choosing appropriate antimicrobials (372 of 1566 [23.8%]
vs 330 of 1767 [18.7%]; OR, 1.36; 95% CI, 1.15-1.60; P < .001) or in choosing narrow-spectrum agents(773 of 1560 [49.6%] vs 750 of 1772 [42.3%]; OR, 1.34; 95% CI, 1.17-1.53; P < .001). However, theassociation was not significant when adjusted for other factors (Table 1). In contrast, the presence ofAS programs was consistently independently associated with these items. Regarding ID physicians’education, multivariable analysis (Table 2) showed that ID department rotation was independently
associated with being able to explain the concept of AS (adjusted odds ratio [aOR], 1.68; 95% CI,1.19-2.37), being confident in choosing appropriate antimicrobials (aOR, 2.21; 95% CI, 1.46-3.36), andtrying to choose narrow-spectrum antimicrobials (aOR, 1.94; 95% CI, 1.42-2.66) when compared withreceiving no education from ID physicians during residency. Similarly, receiving feedback through ID
consultation was independently associated with being able to explain the concept of AS (aOR, 1.49;95% CI, 1.08-2.06) and with trying to choose narrow-spectrum antimicrobials (aOR, 1.42; 95% CI,1.06-1.91).

Discussion
In this nationwide cross-sectional study in Japan, at the institutional level, the presence of a bedside
ID consultation was associated with resident physicians’ enhanced commitment to AS, although its
association was not observed after adjusting for the presence of AS programs. However, at theindividual level, ID department rotation or feedback through ID consultation were independently
associated with improved perceptions and attitudes toward AS among resident physicians. ID
physicians have been reported to exert a positive influence on peer physicians’ antimicrobial
prescription behavior, both indirectly at the institutional level, through cultivating the organizational
culture, and directly at the individual level.6 Our findings further support the value of ID physicians
as educators for resident physicians, particularly when education takes place through patient care.
The limitations include the presence of unmeasured factors, such as differences in the quality,
timing, and duration of AS education and respondents’ motivation to learn AS. Also, resident
physicians’ prescribing practice was not evaluated. Nevertheless, our findings suggest thatempowerment of ID physicians in postgraduate education may complement AS programs and help
promote AS in the long term.

ARTICLE INFORMATION
Accepted for Publication: February 6, 2024.
Published: March 29, 2024. doi:10.1001/jamanetworkopen.2024.4781
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Miwa Tet al. JAMA Network Open.
Corresponding Author: Koh Okamoto, MD, MS, PhD, Department of Infectious Diseases, Graduate School of
Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519,
Japan (kokamoto-tky@umin.ac.jp).
Author Affiliations: Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan (Miwa,Okamoto); Department of Infectious Diseases, Graduate School of Medical and Dental Sciences, Tokyo Medicaland Dental University, Tokyo, Japan (Okamoto); Division of Medical Education, Juntendo University School ofMedicine, Tokyo, Japan (Nishizaki); Muribushi Okinawa Center for Teaching Hospitals, Urasoe, Okinawa, Japan(Tokuda); Tokyo Foundation for Policy Research, Tokyo, Japan (Tokuda).
Author Contributions: Dr Miwa had full access to all of the data in the study and takes responsibility for theintegrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Miwa, Okamoto, Tokuda.

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JAMA Network Open | Medical Education

Infectious Disease Physician Availability and Postgraduate Antimicrobial Stewardship Education in Japan

Critical review of the manuscript for important intellectual content: All authors.
Statistical analysis: Miwa.
Obtained funding: Okamoto, Tokuda.
Administrative, technical, or material support: Okamoto, Nishizaki, Tokuda.
Supervision: Okamoto, Nishizaki, Tokuda.
Conflict of Interest Disclosures: Dr Nishizaki reported receiving personal fees from the Japan Institute forAdvancement of Medical Education Program (JAMEP) during the conduct of the study. Dr Tokuda reported being
the JAMEP director and receiving personal fees from JAMEP during the conduct of the study. No other disclosures
were reported.
Funding/Support: This work was supported in part by a Japan Society for the Promotion of Science KAKENHI
grant (grant No. JP 23K16252 to Dr Okamoto).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection,management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; anddecision to submit the manuscript for publication.
Meeting Presentation: The findings reported here were presented in part at IDWeek 2023; Boston,
Massachusetts; October 12, 2023 (abstract No. 773).
Data Sharing Statement: See Supplement 2.
Additional Contributions: We thank Kazuya Nagasaki, PhD, from the Department of Internal Medicine, Mito
Kyodo General Hospital, Ibaraki, Japan, and the University of Tsukuba, Ibaraki, Japan, for assistance with statisticalanalysis. We also would like to thank Editage (www.editage.jp) for English language editing.
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SUPPLEMENT 1.
eTable. Survey Questions and Possible Response Categories
eMethods.
eReferences.
SUPPLEMENT 2.
Data Sharing Statement

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