Antibiotic stewardship interventions are more effective if they contain enabling components, such as goal setting, feedback and action planning, say the authors of an updated Cochrane review
The review include 221 studies (58 randomised controlled trials and 163 non-randomised studies) from the United States, Europe, Asia, South America and Australia that explored interventions to improve antibiotic prescribing to hospital inpatients.
The researchers, led by Peter Davey at the University of Dundee, classified the interventions from the studies as involving restriction — that is, applying rules to make antibiotic prescribing more appropriate, such as formulary restriction and automated stop orders, or enablement — providing advice and feedback to encourage prescribers to make better prescribing decisions.
The team found that both restriction and enablement were independently associated with increased adherence to antibiotic prescribing guidelines. But adding enablement strategies to restrictive practices further enhanced their efficacy.
“This Cochrane review shows that a wide variety of different interventions have been successful in safely reducing unnecessary antibiotic use in hospitals,” says Davey. “Successful adoption of the interventions we have studied could have considerable impact on health-service policy, and future decision-making for patients.”
Across 29 randomised controlled trials, antibiotic stewardship interventions resulted in an increase in adherence to antibiotic prescribing policy by 19% (95% confidence interval 15–23%) compared with no intervention.
They were also associated with a two-day reduction in the average duration of antibiotic treatment from 11 to 9 days and potentially a reduction in length of hospital stay, by around one day, the team estimates. Additionally, there was some evidence that reduced antibiotic use did not increase the risk of mortality.
The authors of the review say that further research is unlikely to change their conclusions that intervention strategies enhance antibiotic stewardship compared with no intervention. Future research should instead examine what barriers are preventing them from being put into place.
“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,” says Davey. The authors note that only 10% of interventions used the most effective enabling techniques, namely, goal-setting, feedback and action planning.
“Future research should instead focus on targeting treatment and assessing other measures of patient safety, and different interventions that explore the barriers and facilitators to implementation,” says Davey.
The previous version of the review, published in 2013, found that restrictive interventions had a greater immediate effect on prescribing than interventions using education or persuasion, but did not look at enablement.
Since April 2016, NHS England has made available £150m in funding to incentivise hospital clinicians and pharmacists to review and reduce antibiotic prescribing.
But Colin Garner, chief executive of Antibiotic Research UK, says that there needs to be widespread action at a local level for this approach to be effective. “Unless there is a champion in every hospital and practice then this initiative will be only partially successful.”
Pharmacists have a key role to play, Garner adds. “Pharmacists must, and do, play a role in interventionist antibiotic prescribing policies,” he says.
“They should, if they aren’t already, be on every hospital’s antibiotic stewardship committee throughout the UK. They also need to be involved in an antibiotic prescribing audit function to ensure best practice is followed.”
 Davey P, Marwick CA, Scott CL et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Database of Systematic Reviews 2017; 2: CD003543. doi: 10.1002/14651858.CD003543.pub4