Cochrane for Clinicians
Putting Evidence into Practice
Interventions to Improve Antibiotic Prescribing Practices for Hospital Inpatients
Am Fam Physician. 2008 Mar 1;77(5):618-619.
A hospital-based seminar demonstrated an excessive amount of inappropriate antibiotic prescribing for inpatients, and an associated increase in the rate of nosocomial infections and worsening antimicrobial resistance patterns.
What strategies have been proven to improve antibiotic-prescribing practices in hospitalized patients?
The choice of antibiotic, timing, dosage and route of administration in hospitalized patients can be improved through educational (persuasive) and restrictive measures. Although both types of interventions are effective, based on heterogeneous studies, restrictive measures appear to make a more significant change in antibiotic prescribing patterns.1
The public health consequences of inappropriate antimicrobial prescribing are a concern for health care professionals. Rates of nosocomial infections and increasing antimicrobial resistance patterns continue to escalate. Hospitalized patients, especially the critically ill, are at a significant risk of infection with an expanding array of multidrug-resistant organisms.2
Antibiotics have well-known benefits when used appropriately. However, it has been estimated that up to 50 percent of the antibiotic usage in hospitals is inappropriate.3,4 Some of the common errors with antibiotic usage include: administering antimicrobials for noninfectious syndromes; using broad-spectrum antibiotics instead of the appropriate narrow-spectrum antibiotics; extending therapy durations beyond the recommended time frames; and treating colonizing or contaminating organisms.5,6
The authors of this report reviewed 66 studies that identified interventions for improving antibiotic-prescribing practices to hospital inpatients. The review included heterogenous studies (e.g., randomized controlled trials, before-and-after studies, interrupted time series) and evaluated a variety of interventions (57 in total). The measured outcomes varied by study, in which some analyzed the decision to initiate antibiotics, whereas others concentrated on drug selection, dosing interval, or duration of treatment. Because of the differences in study design, it was difficult for the authors to pool results, and they could draw only limited conclusions.
The strongest conclusion from this review came from the comparison of educational and persuasive versus restrictive methods for improving antibiotic prescribing. There were 29 studies that used educational interventions (e.g., reminders, meetings, outreach visits, physician feedback) and 27 that used restrictive methods (e.g., printed care pathways, formulary restrictions, mandated reviews by pharmacists or infectious disease consultants). On average, restrictive methods were three times more effective than persuasive interventions.
Passive educational interventions produced minimal change in physician behavior, and lectures or presentations with little audience interaction or discussion were ineffective. Interactive sessions that included techniques to enhance physician participation (e.g., role-play, discussion groups, hands-on training, problem solving, case solving) showed somewhat more successful results than traditional lecture-based learning.7
Background: Up to 50 percent 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 diarrhea (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 strategy: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialized register, Cochrane Central Register of Controlled Trials, Medline, and Embase from 1980 to November 2003. Additional studies were obtained from the bibliographies of retrieved articles.
Selection criteria: We included all randomized and controlled clinical trials, controlled before and after studies, and interrupted time series 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 percent) 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 increase and decrease treatment. The intervention target was the decision to prescribe antibiotics (one study), timing of first dose (six studies), the regimen (e.g., drug, dosing interval; 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 percent) significantly improved, 16 reported microbiological outcomes of which 12 (75 percent) significantly improved, and nine reported clinical outcomes of which two (22 percent) significantly deteriorated and three (33 percent) significantly improved.
Five studies aimed to reduce CDAD. Three of these showed a significant reduction in CDAD. Because of differences in study design and the 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.
These summaries have been derived from Cochrane reviews published in the Cochrane Database of Systematic Reviews in the Cochrane Library. Their content has, as far as possible, been checked with the authors of the original reviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minor editing changes have been made to the text (http://www.cochrane.org).
Previous research has suggested that the use of multidisciplinary teams, rather than individual “physician champions,” is the most successful strategy for creating a change in a hospital environment.8 Additional academic detailing by individual and group educational-interactive sessions, with aggregated feedback materials on antimicrobial prescribing, has been shown to be effective.9 If an intensive, multifaceted approach is to be undertaken, financial support and direction from hospital administration is necessary. However, most administrators rely on the dissemination of educational materials at short (e.g., lunchtime) educational meetings and provide insufficient funds for more comprehensive programs.8
Address correspondence to Robert Dachs, MD, FAAFP, at email@example.com. Reprints are not available from the author.
The author thanks Simona Sirbu, MD, and Neema Afejuku, MD, for their assistance with the preparation of the manuscript.
Author disclosure: Nothing to disclose.
1. Davey P, Brown E, Fenelon L, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2005;(4):CD003543.
2. Frimodt-Møller N, Rosdahl N, Wegener HC. Microbiological resistance promoted by misuse of antibiotics: a public health concern. Eur J Public Health. 1998;(8):193–194.
3. Fishman N. Antimicrobial stewardship. Am J Med. 2006;119(6 suppl 1):S53–61; discussion S62–70.
4. Great Britain. Parliament. House of Lords. Select Committee on Science and Technology. Resistance to antibiotics and other antimicrobial agents. London, UK: The Stationery Office; 1998. HL Paper 81:1–108.
5. Hecker MT, Aron DC, Patel NP, Lehmann MK, Donskey CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med. 2003;163(8):972–978.
6. Vlahovic-Palcevski V, Morovic M, Palcevski G, Betica-Radic L. Antimicrobial utilization and bacterial resistance at three different hospitals. Eur J Epidemiol. 2001;17(4):375–383.
7. Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282(9):867–874.
8. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):iii–iv,1–72.
9. Mol PG, Wieringa JE, Nannanpanday PV, et al. Improving compliance with hospital antibiotic guidelines: a time-series intervention analysis. J Antimicrob Chemother. 2005;55(4):550–557.
The Cochrane Abstract is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Dr. Dachs presents a clinical scenario and question based on the Cochrane Abstract, followed by an evidence-based answer and a critique of the review. The practice recommendations in this activity are available at http://www.cochrane.org/reviews/en/ab003543.html.
The series coordinator for AFP is Clarissa Kripke, MD, Department of Family and Community Medicine, University of California, San Francisco.
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