Interventions to improve antibiotic prescribing practices for hospital inpatients
Abstract
Background
Up to 50% of antibiotic usage in hospitals is inappropriate. In hospitals, infections caused by antibiotic‐resistant bacteria are associated with higher mortality, morbidity and prolonged hospital stay compared with infections caused by antibiotic‐susceptible bacteria. Clostridium difficile associated diarrhoea (CDAD) is a hospital acquired infection that is caused by antibiotic prescribing.
Objectives
To estimate the effectiveness of professional interventions that alone, or in combination, are effective in promoting prudent antibiotic prescribing to hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial resistant pathogens or CDAD and their impact on clinical outcome.
Search methods
We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialized register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE from 1980 to November 2003. Additional studies were obtained from the bibliographies of retrieved articles
Selection criteria
We included all randomised and controlled clinical trials (RCT/CCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies of antibiotic prescribing to hospital inpatients. Interventions included any professional or structural interventions as defined by EPOC.
Data collection and analysis
Two reviewers extracted data and assessed quality.
Main results
Sixty‐six studies were included and 51 (77%) showed a significant improvement in at least one outcome. Six interventions only aimed to increase treatment, 57 interventions aimed to decrease treatment and three interventions aimed to both increase and decrease treatment. The intervention target was the decision to prescribe antibiotics (one study), timing of first dose (six studies), the regimen (drug, dosing interval etc, 61 studies) or the duration of treatment (10 studies); 12 studies had more than one target. Of the six interventions that aimed to increase treatment, five reported a significant improvement in drug outcomes and one a significant improvement in clinical outcome. Of the 60 interventions that aimed to decrease treatment, 47 reported drug outcomes of which 38 (81%) significantly improved, 16 reported microbiological outcomes of which 12 (75%) significantly improved and nine reported clinical outcomes of which two (22%) significantly deteriorated and 3 (33%) significantly improved. Five studies aimed to reduce CDAD. Three showed a significant reduction in CDAD. Due to differences in study design and duration of follow up, it was only possible to perform meta‐regression on a few studies.
Authors' conclusions
The results show that interventions to improve antibiotic prescribing to hospital inpatients are successful, and can reduce antimicrobial resistance or hospital acquired infections.
PICOs
Plain language summary
Improving how antibiotics are prescribed by physicians working in hospital settings.
Antibiotics are used to treat infections, such as pneumonia, that are caused by bacteria. Over time however, many bacteria have become resistant to antibiotics. Antibiotic resistance is a serious problem for individual patients and health care systems; in hospitals, infections caused by antibiotic‐resistant bacteria are associated with higher rates of death, illness and prolonged hospital stay. Bacteria often become resistant because antibiotics are used too often and incorrectly. Studies have shown that about half of the time, physicians in hospital are not prescribing antibiotics properly. Hospital physicians may be unclear about the benefits and risks of prescribing antibiotics including whether to prescribe an antibiotic, which antibiotic to prescribe, at what dose and for how long.
Many different methods to improve the prescribing of antibiotics in hospitals have been studied. In this review, 66 studies, mostly conducted in North America and the United Kingdom, were analysed to determine what methods work. Six studies tested methods to increase the use of antibiotics to prevent infections (for example, around the time of surgery) ‐ five of the studies showed improvements in prescribing. The other 60 studies tested persuasive and restrictive methods to reduce unnecessary antibiotic use. Persuasive methods advised physicians about how to prescribe or gave them feedback about how they prescribed. Restrictive methods put a limit on how they prescribed; for example, physicians had to have approval from an infection specialist in order to prescribe an antibiotic. Overall, the 60 studies showed that the methods improved prescribing, decreased the number of infections in hospital and decreased death, illness and length of hospital stays and that restrictive methods appeared to have a larger effect than persuasive methods. In conclusion, this review has found a lot of evidence that methods can improve prescribing of antibiotics to patients in hospital but we need more studies to fully assess the clinical benefits of these methods.
