In this blog for non-medical readers, retired GP Dr Lynda Ware, Senior Fellow in General Practice with Cochrane UK, looks at new Cochrane evidenceCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. on reducing unnecessary antibiotic prescribing by hospital doctors.
Page last checked 30 December 2022
Antibiotics are widely used to treat infections caused by bacteria and there is a year on year increase in the number of prescriptions issued. In 2015 NHS England reported a 12% increase in hospital inpatient antibiotic use. Studies have shown that patients who are hospitalised are highly likely to be given antibiotic therapy and up to 50% of all antibiotic use in hospitals may be inappropriate.
The overuse of antibiotics has led to an increase in antibiotic resistance, where antibiotics are no longer able to kill bacteria. This is a major public health problem and can lead to prolonged hospital stays and a higher riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of death. Inappropriate use of antibiotics is also linked to the emergence of healthcare-associated infections such as Clostridium difficile and MRSA, which pose a serious risk to patients, staff and visitors.
The cost of unnecessary antibiotic prescribing and of treating resistant infections is significant.
More than thirty years ago programmes (called Antimicrobial Stewardship) were introduced in hospitals to address inappropriate antibiotic prescribing and the increase in antibiotic resistance rates.
A Cochrane Review Interventions to improve antibiotic prescribing practices for hospital inpatients (published February 2017) looks at interventions to change doctors’ behaviour and improve antibiotic prescribing for hospital inpatients.
What did the Cochrane reviewCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. look at?
The aim of the review was to assess different ways in which antibiotic prescribing to hospital inpatients might be improved. Two particular interventions were studied: restrictive interventions, where prescribing was carefully controlled and enabling interventions, where clinicians were helped to prescribe more appropriately by advice and feedback.
The reviewers found 221 studies, the majority of which came from Europe and North America. There were 58 randomizedRandomization is the process of randomly dividing into groups the people taking part in a trial. One group (the intervention group) will be given the intervention being tested (for example a drug, surgery, or exercise) and compared with a group which does not receive the intervention (the control group). controlled trialsA trial in which a group (the ‘intervention group’) is given a intervention being tested (for example a drug, surgery, or exercise) is compared with a group which does not receive the intervention (the ‘control group’). (RCTs) and 163 non-randomizedA non-randomised study is any quantitative study estimating the effectiveness of an intervention (harm or benefit) that does not use randomisation to allocate people to comparison groups. studies (NRS). The studies looked at the effectivenessThe ability of an intervention (for example a drug, surgery, or exercise) to produce a desired effect, such as reduce symptoms. and safetyRefers to serious adverse effects, such as those that threaten life, require or prolong hospitalization, result in permanent disability, or cause birth defects. of the interventions and, in the main, compared prescribing patterns and clinical outcomesOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’. with and without an interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. added to usual hospital prescribing policy. The interventions were delivered in different ways e.g. 51% of the studies included interventions designed and delivered by a multidisciplinary team, 24% by specialist physicians (infectious diseases or microbiology) and 9% by pharmacists.
What did the review find?
DataData is the information collected through research. from 29 RCTs with 23,394 participants showed that when an intervention was in place more hospital patients were treated according to antibiotic prescribing policy. There was a 15% increase in compliance from 43% to 58%. This evidence was assessed as being of high certainty, which means that further research is unlikely to change the conclusions.
There was high certainty evidence from 14 RCTs with 3318 participants that the duration of antibiotic treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. decreased by two days (from 11 days to 9 per patient).
The interventions probably reduced the length of hospital stay from 13 days to 12 (15 RCTs with 3834 participants and moderate certainty evidence – this means that further research might change the conclusions). The risk of death was 11% for both the intervention and the no intervention control groups (28 RCTs, 15,827 participants and moderate certainty evidence), suggesting that reducing antibiotic prescribing did not lead to an increase in harm.
Looking more closely at the kinds of interventions used, the review showed that both restrictive and enabling interventions increased compliance to antibiotic prescribing policies (high-certaintyThe certainty (or quality) of evidence is the extent to which we can be confident that what the research tells us about a particular treatment effect is likely to be accurate. Concerns about factors such as bias can reduce the certainty of the evidence. Evidence may be of high certainty; moderate certainty; low certainty or very-low certainty. Cochrane has adopted the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) for assessing certainty (or quality) of evidence. Find out more here: https://training.cochrane.org/grade-approach evidence). Enabling interventions were better accepted by staff (perhaps not surprisingly) and, when combined with restrictive measures, improved adherence to prescribing rules. The most effective enabling technique appeared to be feedback to the prescribing physicians.
There was only very low certainty evidence about the effect that the interventions had on reducing hospital infections.
What more do we need to know?
Peter Davey, lead author of the Cochrane Review summed this up :
“We do not need more studies to answer the question of whether these interventions reduce antibiotic use, but we do need more research to understand why the most effective behavioural techniques are not more widely adopted within hospital settings.”
The interventions included in this review are effective and safe but, as can be seen from the data, compliance to prescribing guidelines increased from 43% to 58%, indicating that there is still room for improvement.
The studies were mostly from Europe and North America. Antibiotic resistance is a global problem and ways to implement antibiotic stewardship must be sought worldwide.
The data in this review do not provide an answer to the question as to whether improving antibiotic prescribing reverses antibiotic resistance rates. This will require longer-term studies to assess the impact of stewardship measures.
From Diamantis Plachouras (European Centre for Disease Prevention and Control, Stockholm) and Susan Hopkins (Public Health England, London) :
“’Antimicrobial stewardship is effective and safe. We need to ensure that it is implemented, and this Cochrane Review highlights two key delivery methods. Political commitment and adequate funding will be essential if antimicrobial stewardship is to be implemented in every healthcare setting.”
Full citation: Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, Gould IM, Ramsay CR, Michie S. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic ReviewsIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. 2017, Issue 2. Art. No.: CD003543. DOI: 10.1002/14651858.CD003543.pub4.
Lynda Ware has nothing to disclose.
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