Completed project: Improved prescribing thanks to continuous feedback
A programme in which hospital doctors discuss with infectious disease specialists on a weekly basis has led to improved antibiotic prescribing.
As antibiotic resistance is correlated to antibiotic consumption, there is a need not only to support professionals and patients in reducing unnecessary use of antibiotics, but also to optimise the appropriateness of prescriptions (duration, route of administration, dosage or spectrum). Special programmes to support prescribing doctors, so-called stewardship programmes, have been shown to improve antibiotic prescribing practices in the hospital setting. Nevertheless, such interventions are so far limited in Switzerland, although there is evidence of unnecessary or inappropriate antibiotic therapy in Swiss hospitals.
Training and feedback as core measures
To support hospital doctors in prescribing, researchers at the CHUV led by Laurence Senn developed and tested a programme in which infectious diseases specialists provided training to hospital doctors. Together with a senior physician, they also reviewed the doctors' prescribing habits on a weekly basis and discussed their findings with them. A key element of the multifaceted feedback strategy was a study website targeting prescribers (see link below). The programme focused on specific broad-spectrum antibiotics that are prescribed to treat infections potentially caused by so-called gram-negative bacteria. The researchers conducted and evaluated the intervention over six months in 8 acute care hospitals in four cantons (Fribourg, Neuchâtel, Valais und Vaud) in internal medicine, general surgery and intensive care units. The units were allocated to either an intervention group, which implemented the programme, or to a control group, which didn't do so. The allocation of the wards was done randomly.
Modification of therapy proposed in a quarter of cases
During the study, nearly 10,000 in-patients were screened among whom more than 1500 received a broad-spectrum antibiotic the researchers were focused on. In a quarter of these cases, the specialists proposed a modification of the antibiotic therapy. Most often, they suggested to stop the antibiotic treatment, followed by de-escalation (reducing the spectrum) and a switch from intravenous to oral intake. However, there were clear differences in the prescriptions assessed as inappropriate between the wards studied: In intensive care medicine, about one tenth of the prescriptions examined were assessed as inappropriate, in surgery about one third.
Need for long-term programmes
The researchers' intervention led to a slight decrease in the use of most critical antibiotics during the six-month study period, with no change for some. Given the overall good prescribing practice (about three quarters of all prescriptions were judged to be correct), the researchers consider this effect a success. The study shows that there is a need to raise awareness among prescribing physicians of the importance of daily reassessment of antibacterial prescriptions and the systematic scheduling of a stop date. The results provide a basis for future long-term stewardship programmes by showing which type of ward, antibiotic or optimisation should be targeted by future interventions. In order to achieve an optimisation of antibiotic use in hospitals, the researchers recommend implementing a multifaceted strategy including feedbacks, teaching rounds, continuous education, provision of guidelines and educative material including decision-supporting tools.