Intervention Review

Interventions to improve antibiotic prescribing practices for hospital inpatients

  1. Peter Davey1,*,
  2. Erwin Brown2,
  3. Lynda Fenelon3,
  4. Roger Finch4,
  5. Ian Gould5,
  6. Giles Hartman6,
  7. Alison Holmes7,
  8. Craig Ramsay8,
  9. Eric Taylor9,
  10. Mark Wilcox10,
  11. Philip J Wiffen11

Editorial Group: Cochrane Effective Practice and Organisation of Care Group

Published Online: 15 APR 2009

Assessed as up-to-date: 27 JUL 2005

DOI: 10.1002/14651858.CD003543.pub2

Database Title

Additional Information

How to Cite

Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, Holmes A, Ramsay C, Taylor E, Wilcox M, Wiffen PJ. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003543. DOI: 10.1002/14651858.CD003543.pub2.

Author Information

  1. 1

    University of Dundee, Division of Clinical and Population Sciences and Education, Dundee, Scotland, UK

  2. 2

    Frenchay Hospital, Department of Pathology, Bristol, UK

  3. 3

    St Vincent's University Hospital, Department of Microbiology, Dublin 4, Republic of Ireland, Ireland

  4. 4

    Clinical Sciences Building, City Hospital, Division of Microbiology and Infectious Diseases, Nottingham, UK

  5. 5

    Aberdeen Royal Infirmary, Department of Medical Microbiology, Aberdeen , UK

  6. 6

    J Floor, Old Main Building, J47 86 Senior Consultant's Corridor, Observatory, Cape Town, South Africa

  7. 7

    Imperial College of Science, Technology and Medicine, Department of Infectious Diseases and Microbiology, London, UK

  8. 8

    University of Aberdeen, Health Services Research Unit, Division of Applied Health Sciences, Aberdeen, UK

  9. 9

    Inverclyde Royal Hospital, Greenock, UK

  10. 10

    University of Leeds, Department of Microbiology, Leeds, UK

  11. 11

    UK Cochrane Centre, Oxford, UK

*Peter Davey, Division of Clinical and Population Sciences and Education, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, Scotland, DD2 4BF, UK. p.g.davey@cpse.dundee.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 15 APR 2009

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Up to 50% 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 diarrhoea (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 methods

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialized register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE from 1980 to November 2003. Additional studies were obtained from the bibliographies of retrieved articles

Selection criteria

We included all randomised and controlled clinical trials (RCT/CCT), controlled before and after studies (CBA) and interrupted time series (ITS) 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%) 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 both increase and decrease treatment. The intervention target was the decision to prescribe antibiotics (one study), timing of first dose (six studies), the regimen (drug, dosing interval etc, 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%) significantly improved, 16 reported microbiological outcomes of which 12 (75%) significantly improved and nine reported clinical outcomes of which two (22%) significantly deteriorated and 3 (33%) significantly improved. Five studies aimed to reduce CDAD. Three showed a significant reduction in CDAD. Due to differences in study design and 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.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Improving how antibiotics are prescribed by physicians working in hospital settings.

Antibiotics are used to treat infections, such as pneumonia, that are caused by bacteria. Over time however, many bacteria have become resistant to antibiotics. Antibiotic resistance is a serious problem for individual patients and health care systems; in hospitals, infections caused by antibiotic-resistant bacteria are associated with higher rates of death, illness and prolonged hospital stay. Bacteria often become resistant because antibiotics are used too often and incorrectly. Studies have shown that about half of the time, physicians in hospital are not prescribing antibiotics properly. Hospital physicians may be unclear about the benefits and risks of prescribing antibiotics including whether to prescribe an antibiotic, which antibiotic to prescribe, at what dose and for how long.

Many different methods to improve the prescribing of antibiotics in hospitals have been studied. In this review, 66 studies, mostly conducted in North America and the United Kingdom, were analysed to determine what methods work. Six studies tested methods to increase the use of antibiotics to prevent infections (for example, around the time of surgery) - five of the studies showed improvements in prescribing. The other 60 studies tested persuasive and restrictive methods to reduce unnecessary antibiotic use. Persuasive methods advised physicians about how to prescribe or gave them feedback about how they prescribed. Restrictive methods put a limit on how they prescribed; for example, physicians had to have approval from an infection specialist in order to prescribe an antibiotic. Overall, the 60 studies showed that the methods improved prescribing, decreased the number of infections in hospital and decreased death, illness and length of hospital stays and that restrictive methods appeared to have a larger effect than persuasive methods. In conclusion, this review has found a lot of evidence that methods can improve prescribing of antibiotics to patients in hospital but we need more studies to fully assess the clinical benefits of these methods.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

改善對於醫院住院病人其抗生素處方做法的介入措施

醫院中有高達50%的抗生素使用不當。相較於經由抗生素感受性的細菌感染造成的醫院感染，抗生素抗藥性細菌所造成的醫院感染與較高的死亡率，罹病率及長期住院有關。難治型腸梭菌相關腹瀉(Clostridium difficile associated diarrhoea (CDAD))是一種後天的醫院感染，其導因於開立抗生素處方。

目標

評估單一或合併的專家介入措施對於推廣謹慎開立抗生素處方與醫院住院病人的效果，評估這些介入措施對於減少抗微生物抗藥性病原體或CDAD及他們對臨床結果的影響。

搜尋策略

我們檢索1980至2003年11月的the Cochrane Effective Practice and Organisation of Care (EPOC) specialized register，Cochrane Central Register of Controlled Trials，MEDLINE，EMBASE。從相關文章的參考書目取得其他研究。

選擇標準

我們納入所有開立抗生素處方予醫院住院病人的隨機及對照的臨床試驗(randomised及controlled clinical trials (RCT/CCT))，前後對照研究(controlled before and after studies (CBA))及間斷時間序列(interrupted time series (ITS))研究。介入措施包括任何專家或如EPOC定義之結構化的介入措施。

資料收集與分析

兩名回顧者摘錄資料並評估品質。

主要結論

共納入66篇研究且51篇(77%)顯示至少有一項結果有顯著改善。6種介入措施的目的只為了增加治療，57種介入措施的目的為減少治療而3種介入措施的目的為增加及減少治療兩者。介入措施的目標為開立抗生素處方的決定(1篇研究)，第一劑的時機(6篇研究)，藥物方案(藥物，給藥間隔等，61篇研究)或治療期間長短(10篇研究)；12篇研究有一項以上的目標。目的為增加治療的6種介入措施中，5種介入措施可以顯著改善藥物結果，而一種介入措施可以顯著改善臨床結果。目的為減少治療的60種介入措施中，47種介入措施報告關於藥物的結果，其中38種介入措施(81%)有顯著改善，16篇報告關於微生物的結果，其中12種介入措施(75%)有顯著改善，而9種介入措施報告關於臨床結果，其中2種介入措施有顯著惡化，而3種有顯著改善。5篇研究目的為減少CDAD。其中三篇顯示有顯著減少CDAD。由於研究設計及追蹤期的差異，只有幾篇研究可進行統合回歸分析。

作者結論

結果顯示用來改善開立抗生素處方與醫院住院病人的介入措施是成功的，且可以減少抗微生物的抗藥性或後天的醫院感染。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

改善醫院機構中醫師開立抗生素處方的做法。抗生素被用來治療細菌引起的感染，如肺炎。然而，隨著時間過去，許多細菌會對抗生素產生抗藥性。抗生素的抗藥性對於個別病患及健康照護系統來說是一種嚴重的問題；在醫院，經由抗生素抗藥性的細菌引起的感染與較高的死亡率，疾病及長期住院天數有關。細菌轉變成抗藥性是因為太常且不適當的使用抗生素。研究顯示，約有一半的時間，醫院中的醫師不適當的開立抗生素處方。醫院的醫師也許不清楚開立抗生素處方的效益及風險，包括是否開立抗生素處方，開立何種抗生素處方，何種劑量與天數。許多用來改善醫院中開立抗生素處方的方不同法已經被研究。這篇回顧中，66篇研究大部分在北美及英國進行，分析這些研究以確定何種方法發揮作用。6篇研究測試增加抗生素使用以預防感染的方法(例如，手術前後)，其中5篇研究顯示會改善處方的開立。其他的60篇研究測試說服及限制性的方法用以減少非必要的抗生素使用。說服的方法是建議醫師有關如何開立處方或給予他們開立處方結果的回饋。限制性的方法是限制他們開立處方，例如，醫師開立抗生素處方必須有感染科醫師的認同。整體來說，60篇研究顯示這些方法可以改善處方的開立，減少醫院感染的數量及減少死亡，疾病與住院天數，且限制性的方法似乎比說服的方法有較大的影響。總而言之，這篇回顧發現許多可以改善開立抗生素處方予醫院病患的方法的證據，但我們仍需要更多的研究以全盤評估這些方法的臨床效益。

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