Interventions Do Improve Antibiotic Prescribing, Cochrane Review Shows

Diana Swift

February 10, 2017

Both restriction and enablement interventions helped physicians adhere to prescribing guidelines and avoid overuse of antibiotics, according to a Cochrane Review published online February 9.

Restrictive techniques centered on guidelines and regulations aimed at limiting antibiotic prescribing while enabling measures aimed at improving the quality of prescribing, including providing advice and feedback to help physicians make more targeted prescribing decisions. Both were designed to increase appropriate decision making, so only patients likely to benefit from antibiotics received them.

The review found that hospital guidelines for more targeted prescribing were more effective if they were supported by measures designed to alter physician behavior. "Antibiotic stewardship works best when interventions enable prescribers in the workplace," lead author Peter G. Davey, MD, an infectious disease specialist and lead clinician for quality improvement, Population Health Sciences, the University of Dundee, Scotland, told Medscape Medical News.

"Prescribers need to be involved in understanding the consequences of their intervention, good and bad."

Dr Davey added that practical application of effective behavior modification techniques in the workplace is "the key to achieve sustainable improvement at scale."

Studies have shown that physicians in hospitals often prescribe unnecessary antimicrobials, thereby raising the risk for nosocomial infections from antibiotic-resistant bacteria.

"[A]ntibiotic resistance is largely a consequence of the selective pressures of antibiotic usage, and...reducing these pressures by the judicious administration of antibiotics will facilitate a return of susceptible bacteria or, at least, will prevent or slow the pace of the emergence of resistant strains," Dr Davey and colleagues write in the review.

Interventions Improve Prescribing

In a literature search, Dr Davey and colleagues identified 221 studies published up to January 2015 and analyzed data from 29 high-quality, although often heterogeneous, randomized trials involving 23,394 inpatients. Patients were receiving acute hospital care or undergoing surgery and were subject to stewardship intervention or standard care with no intervention.

Enabling measures included physician audit and feedback on clinical performance, education through meetings or disseminated educational materials, circumstantial verbal or print reminders in the workplace, and reviews of individual patient care with recommendations for change.

Restrictive interventions entailed selective reporting of laboratory susceptibilities, formulary restriction, requiring expert authorization for therapeutic substitution, and automatic stop orders.

Dr Davey and colleagues also took account of systemic factors such as switching to electronic patient records and new technologies for rapid microbiology testing.

"We found high-certainty evidence that interventions lead to more hospital inpatients receiving the appropriate treatment for their condition according to antibiotic prescribing policies," the researchers write.

With both approaches, 58% of inpatients were treated according to prescribing guidelines vs 43% of those assigned to standard no-intervention care. Interventions shortened antibiotic use by 1.95 (95% confidence interval [CI], 2.22 - 1.67) days from 11.0 days per patient, and likely shortened hospital stays by 1.12 days (95% CI, 0.7 - 1.54 days) from a mean of 12.9 days per patient.

Moreover, among the studies that evaluated the risk for death, there was no difference, with risk at 11% in both the intervention and control groups, suggesting that curtailing antibiotic use did not increase mortality.

As for infections, the researchers found only very low-certainty evidence in 26 studies that interventions reduced in-hospital Clostridium difficile infections or resistant gram-negative and gram-positive bacteria. "There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use," they write.

Calling the reduction of antimicrobial resistance and in-hospital infections a public health priority, the authors recommended an enhanced role for feedback, which was used in just 10% of enablement interventions, and very few of these also included setting concrete goals and planning remedial action.

"Antimicrobial management teams might consider using evidence about effective feedback from other clinical settings," they write. "Training in the design and reporting of behaviour change interventions should be a priority for antimicrobial management teams."

In the meantime, some signs point to improvement. "There are beacons both in reducing C difficile antimicrobial-resistant infections and in improving sepsis outcomes," Dr Davey said. He pointed to the future importance of "using behavior change theory to understand what works, and looking at all of the consequences of interventions."

According to the authors, future research should examine factors that impede or expedite the implementation of stewardship, and "[m]ore research is required on unintended consequences of restrictive interventions," they write.

They note, however, that more studies are not warranted to test the overall value of intervention vs placebo with respect to improving prescribing practices.

As reported previously by Medscape Medical News, a 2016 national study showed that just 39% of US hospitals have antimicrobial stewardship programs, although the proportion varies widely between states, from 7% in Vermont to 58% in California.

The institutions of three coauthors received funding from the Chief Scientist Office in support of this review. The authors have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. 2017;2:CD003543. Full text

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