October, 2016 - SUPPORT Summary of a systematic review | print this article |

What is the effectiveness of interventions to improve antibiotic prescribing practices for hospital inpatients?

In-hospital infections caused by antibiotic-resistant bacteria and Clostridium difficile are associated with higher rates of death, illness and prolonged hospital stay which is a serious problem for patients and healthcare systems. These infections occur because antibiotics are used too often and incorrectly.

Key messages

  • Restrictive interventions may improve antibiotic prescribing at one month, but may lead to little or no difference in antibiotic prescribing at longer follow-up compared with persuasive interventions.
  • Interventions intended to decrease unnecessary antibiotic prescribing probably lead to little or no difference in all-cause mortality.
  • It is uncertain whether interventions intended to decrease unnecessary antibiotic prescribing affect the length of stay or readmissions.
  • Interventions intended to increase effective antibiotic prescribing for pneumonia may decrease mortality.
  • None of the included studies were conducted in a low-income country.

 

Background

Antibiotic usage in hospitals is increasing and over a third of prescriptions are not compliant with evidence-based guidelines. One of the consequences, besides worse patient outcomes, is antimicrobial resistance which is considered a major public health problem in terms of health outcomes and costs. This review assessed the effects of professional interventions in antibiotic stewardship for hospital inpatients.

‘Antibiotic stewardship’ is used to capture the twin aims of ensuring effective treatment of patients with infection and minimizing collateral damage from antimicrobial use through appropriate antibiotic prescribing. The interventions were classified as: persuasive (dissemination of educational materials in printed form or via educational meetings reminders, audit and feedback, educational outreach); restrictive (financial and healthcare system changes as compulsory order form, expert approval, removing restricted antibiotics from drug cupboards, changing of prescription by reviewers); and structural (new technology for laboratory testing or computerized decision support).

 



About the systematic review underlying this summary

Review objectives:To assess the effectiveness of professional interventions that, alone or in combination, are effective in antibiotic stewardship for hospital inpatients.
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies of interventions directed to antibiotic stewardship
89 included studies (95 interventions): 25 randomised trials, 3 non-randomised trials, 5 controlled before-after studies, and 56 interrupted time series studies. 84% of the interventions targeted the antibiotic prescribed and the remaining 16% aimed to change exposure of patients to antibiotics by targeting the decision to treat or the duration of treatment.
Participants Healthcare professionals who prescribe antibiotics to hospital inpatients
Interventions were delivered by multidisciplinary teams (39%), specialist physicians in infectious diseases or microbiology (33%), pharmacists (20%), and department physicians (8%).
Settings Hospital settings worldwide
USA (48), UK (12), Netherlands (6), Canada (4), Switzerland (3), Australia (3), Thailand (2), Colombia (2), France (2), Germany (2), Spain (2), Israel (2), Austria (1), Belgium (1), Brazil (1), Hong Kong (1), Italy (1), Norway (1), and Sweden (1)
Outcomes Antibiotic prescribing process measures (decision to treat, choice of drug, dose, route or duration of treatment); clinical outcome measures (mortality, length of hospital stay); microbial outcome measure (colonization or infection with clostridium difficile or antibiotic-resistant bacteria)
Appropriate prescribing of antibiotics, microbial outcomes, patient outcomes (mortality), length of stay, readmissions
Date of most recent search: February 2009
Limitations: This is a well-conducted systematic review with only minor limitations.

Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews 2013; 4:CD003543.

Summary of findings

89 studies were included. Of the 95 interventions reported in these studies, 79 aimed to decrease excessive antibiotic use, 11 aimed to increase effective treatment and 5 aimed to reduce inappropriate antibiotic use but did not distinguish between excessive and ineffective use.

1) Restrictive versus persuasive interventions to improve antibiotic prescribing 

Appropriate prescribing of antibiotics was assessed by 53 indirect comparisons from 40 studies and microbial outcomes by 20 indirect comparisons from 14 studies.

  • Restrictive interventions may improve antibiotic prescribing at one month but may lead to little or no difference at longer follow-up compared with persuasive interventions. The certainty of this evidence is low.
  • Restrictive interventions may improve antibiotic prescribing at six months but may lead to little or no difference at longer follow-up compared with persuasive interventions. The certainty of this evidence is low.

Restrictive versus persuasive interventions to improve antibiotic prescribing

People              Healthcare professionals

Settings            Secondary care (inpatients in acute, not long term care only)

Intervention     Restrictive interventions (compared to usual care in studies)

Comparison      Persuasive interventions (compared to usual care in studies)

Outcomes

Impact (percent change in level)

Certainty

of the evidence

(GRADE)

Appropriate prescribing of antibiotics

The change was 32% larger for restrictive interventions at one month (95% CI 2 to 61%) compared to persuasive interventions and there was little or no difference at 6, 12, and 24 months.

Low†

Microbial outcomes

(colonization or infection with Clostridium difficile or antibiotic-resistant bacteria)

The change was 53% larger for restrictive interventions at 6 months (95% CI 31 to 75%) compared to persuasive interventions and there was little or no difference at 12 and 24 months.

Low†

GRADE: GRADE Working Group grades of evidence (see above and last page)

† Indirect comparison between studies that provide data about effect of either persuasive or restrictive interventions


2) Interventions intended to decrease unnecessary antibiotic prescribing

Mortality was assessed by 11 comparisons from 11 studies; length of stay by six comparisons from six studies and readmissions by five comparisons from five studies.

  • Interventions intended to decrease unnecessary antibiotic prescribing probably lead to little or no difference in all-cause mortality. The certainty of this evidence is moderate.
  • It is uncertain whether interventions intended to decrease unnecessary antibiotic prescribing affect the length of stay or readmissions. The certainty of this evidence is very low.

Interventions intended to decrease unnecessary antibiotic prescribing

People                Healthcare professionals

Settings              Secondary care (inpatients in acute, not long term care only)

Intervention       Interventions intended to decrease unnecessary antibiotic prescribing

Comparison        Usual care

Outcomes

Impact

Certainty

of the evidence

(GRADE)

All-cause mortality

Risk ratio for intervention versus control 0.92 (95% CI 0.81 to 1.06)

Moderate

Length of stay

Difference (in days) for intervention versus control

-0.04 days (95% CI - 0.34 to 0.25)

 

Very low

Readmissions

Risk ratio for intervention versus control 1.26 (95% CI 1.02 to 1.57)

 

Very low

GRADE: GRADE Working Group grades of evidence (see above and last page)

 

3) Interventions intended to increase effective antibiotic prescribing for pneumonia

Mortality was assessed by four comparisons from four studies.

  • Interventions intended to increase effective antibiotic prescribing for pneumonia may decrease mortality. The certainty of this evidence is low.

Interventions intended to increase effective antibiotic prescribing for pneumonia

People              Healthcare professionals

Settings            Secondary care (inpatients in acute care only)

Intervention     Interventions intended to increase effective antibiotic prescribing for pneumonia

Comparison      Usual care

Outcomes

Impact

Certainty

of the evidence

(GRADE)

Mortality

Risk ratio for intervention versus control 0.89 (95% CI 0.82 to 0.97)

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
None of the included studies were conducted in a low-income country.

When assessing the transferability of these findings to low-income countries the following factors should be considered:

− The availability of resources specially for persuasive and structural interventions

− The acceptability and costs of the interventions

Locally tailored up to date antibiotic treatment guidelines


EQUITY
There was no information in the included studies regarding differential effects of the interventions on resource-disadvantaged populations.

Resources needed for interventions may be less available in disadvantaged settings.

The interventions may increase inequity if they are not applied or adapted to these populations.


ECONOMIC CONSIDERATIONS
Limited data showed that savings exceeded the cost of the intervention in 8 out of 10 studies.

Scaling up many of the interventions will require resources, that should be considered.

Local costing should be undertaken, particularly in settings differing from the original investigations.


MONITORING & EVALUATION
There is evidence that interventions to improve antibiotic prescribing for pneumonia may decrease mortality. No clear evidence of benefit and safety was found for other outcomes.

Future studies should provide information about the resources required for development, dissemination and implementation of guidelines and other relevant interventions.

Larger and more rigorous studies to determine the effectiveness, safety and cost-effectiveness of interventions are needed, particularly in resource-poor settings.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods


 

Additional information

Related literature

Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices. Virulence 2013; 4(2):192-202.

Aryee A, Price N. Antimicrobial stewardship – can we afford to do without it? British Journal of Clinical Pharmacology 2015; 79(2):173-81.

Chung GW, Wu JE, Yeo CL, Chan D, Hsu LY. Antimicrobial stewardship: a review of prospective audit and feedback systems and an objective evaluation of outcomes. Virulence 2013; 4(2):151-7.

Reed EE, Stevenson KB, West JE, et al. Impact of formulary restriction with prior authorization by an antimicrobial stewardship program. Virulence 2013; 4(2):158-62.

Wagner B, Filice GA, Drekonja D, et al. Antimicrobial stewardship programs in inpatient hospital settings: a systematic review. Infection Control and Hospital Epidemiology 2014; 35(10):1209-28.

Chandy SJ, Naik GS, Charles R, et al. The impact of policy guidelines on hospital antibiotic use over a decade: a segmented time series analysis. PloS One 2014; 9(3):e92206.

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Gavin Barlow, Göran Tomson, and Peter Davey.

 

This review should be cited as

Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews 2013; 4:CD003543.

 

The summary should be cited as

Ciapponi A. Do interventions improve antibiotic prescribing to hospital inpatients? A SUPPORT Summary of a systematic review. October 2016. www.supportsummaries.org

 

Keywords

All Summaries:

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low- and middle- income countries, developing countries, primary health care; antibiotic prescribing, hospital inpatients, antimicrobial stewardship, antibiotic policies, implementation strategies

 



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