Review finds antibiotic stewardship works but not optimally

Nurse giving pills
Nurse giving pills

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An updated Cochrane Review found that interventions to improve antibiotic prescribing in hospitals result in better compliance with prescribing guidelines, reduced duration of antibiotic treatment, and shorter hospital stays without any impact on mortality—but they could have a greater impact if they used the most effective strategies.

Cochrane Reviews, considered by many to be the gold standard in evidence-based medicine, are systematic reviews of published studies that look at the effects of medical interventions. The purpose of today's review was to estimate the safety and effectiveness of common antibiotic prescribing interventions and evaluate how these interventions could be more successful in reducing inappropriate antibiotic use, which is considered a key driver in antibiotic resistance.

Cochrane's previous review of antibiotic prescribing interventions was in 2013.

Better prescribing, shorter hospital stays

For the updated review, researchers looked at 221 randomized controlled trials (RCTs) and non-randomized trials, mostly from the United States and Europe, that evaluated two main types of antibiotic prescribing interventions in hospitals: restrictive techniques and enablement techniques.

Restrictive techniques include policies that put a limit on which antibiotics can be prescribed. Enablement techniques—which include education, verbal and written reminders, and evaluation of individual physicians' prescribing habits through audit and feedback—are intended to help physicians make better prescribing decisions.

The review found, with high certainty, that 58% of hospital patients were treated according to antibiotic prescribing guidelines when antibiotic interventions were in place, compared with 43% of patients in hospitals that had no antibiotic intervention. That finding was based on 29 RCTs of predominantly enablement interventions involving more than 23,000 patients.

Fourteen RCTs showed, also with high certainty, that antibiotic interventions reduced the duration of antibiotic treatment by nearly 2 days, from 11 to 9.1 days.

When the authors evaluated 15 RCTs for the clinical impact of antibiotic reduction, they found that antibiotic intervention reduced the mean length of hospital stay per patient from 12.9 days to 11.8 days, while 28 RCTs showed no difference in the mortality rate (11%) for intervention and non-intervention groups . Evidence for these conclusions was considered to be of moderate certainty.

There was limited evidence for an association between antibiotic interventions and a decrease in hospital infections such as Clostridium difficile.

Only 10% use optimal strategies

"The randomized controlled trials provided high-certainty evidence that interventions are effective in increasing compliance with guidelines to reduce unnecessary treatment without an increase in mortality," the authors write. "Furthermore, interventions were associated with a reduction in length of stay.

"The evidence from this review should inform implementation decisions regarding antimicrobial stewardship interventions in hospitals"

The review also found, in looking at the effectiveness of the intervention techniques, that restriction and enablement were both independently associated with increased compliance with prescribing guidelines, and were more effective than education alone. But enablement "consistently increased the effectiveness of interventions, including restrictive interventions." And enablement interventions that included audit and feedback and goal-setting for physicians further increased effectiveness. Yet only 10% of the interventions used these strategies.

Lead author Peter Davey, MD, a professor at the University of Dundee School of Medicine in Scotland, said future research needs to focus on why the most successful antibiotic stewardship strategies aren't being used.

"We do not need more studies to answer the question of whether these interventions reduce unnecessary antibiotic use, but we do need more research to understand why the most effective behaviour change techniques are not more widely adopted within hospital settings," Davey said in a press release from Wiley, publisher of the Cochrane Review.

In addition, Davey and his colleagues note that while antibiotic intervention strategies increased adherence to prescribing guidelines by 15%, a 58% compliance rate is still too low.

See also:

Feb 9 Cochrane Review

Feb 8 Wiley press release

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