There is limited evidence from multicenter, randomized controlled studies to inform planning and implementation of antibiotic stewardship interventions in hospitals.
A cluster randomized, controlled, intervention study was performed in selected specialities (infectious diseases, pulmonary medicine and gastroenterology) at three emergency care hospitals in Western Norway. Interventions applied were audit with feedback and academic detailing. Implementation strategies included co-design of interventions with stakeholders in local intervention teams and prescribers setting local targets for change in antibiotic prescribing behaviour. Primary outcome measures were adherence to national guidelines, use of broad-spectrum antibiotics and change in locally defined targets of change in prescribing behaviour. Secondary outcome measures were length of stay, 30-day readmission, in-hospital- and 30-day mortality.
One thousand eight hundred two patients receiving antibiotic treatment were included. Adherence to guidelines had an absolute increase from 60 to 66% for all intervention wards (p = 0.04). Effects differed across specialties and pulmonary intervention wards achieved a 14% absolute increase in adherence (p = 0.003), while no change was observed for other specialties. A pulmonary ward targeting increased use of penicillin G 2 mill IU × 4 for pneumonia and COPD exacerbations had an intended increase of 30% for this prescribing behaviour (p < 0.001).
Pulmonary wards had a higher increase in adherence, independent of applied intervention. The effect of antibiotic stewardship interventions is dependent on how and in which context they are implemented. Additional effects of interventions are seen when stakeholders discuss ward prescribing behaviour and agree on specific targets for changes in prescribing practice.
Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51–77. CrossRefPubMedPubMedCentral
Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews. 2017 Issue 2. Art.nr.: CD003543; doi: https://doi.org/10.1002/14651858.
Stenehjem E, Hersh AL, Buckel WR, Jones P, Sheng X, Evans RS, et al. Impact of implementing antibiotic stewardship programs in 15 small hospitals: a cluster-randomized intervention. Clin Infect Dis. 2018; https://doi.org/10.1093/cid/ciy155.
Wathne JS, Kleppe LK, Harthug S, Blix HS, Nilsen RM, Thelle A, et al., editors. The effect of antibiotic stewardship interventions with stakeholder involvement in multispecialty settings: a multicentre, cluster randomized controlled intervention study. ECCMID 2018, accepted abstract (Oral presentation O0846); 2018 23.04.2018; Madrid; 2018.
WHO Collaborating Centre for Drug Statistics Methodology. ATC Index with DDDs. Norwegian Insitute of Public Health. 2017. https://www.whocc.no/atc_ddd_index/. Accessed 15 Dec 2017.
NORM/NORM-VET. Usage of Antimicrobial Agents and Occurrence of Antimicrobial Resistance in Norway 2016. Tromso/Oslo: Norwegian surveillance system for antibiotic resistance in microbes (NORM), Norwegian Veterinary Institute, Norwegian Institute of Public Health, . 2017. https://unn.no/Documents/Kompetansetjenester,%20-sentre%20og%20fagråd/NORM%20-%20Norsk%20overvåkingssystem%20for%20antibiotikaresistens%20hos%20mikrober/Rapporter/NORM%20NORM-VET%202016.pdf. Accessed 5 Dec 2017.
Norwegian Ministry of Health and Care Services. Action plan against antibiotic resistance in health care. 2015. https://www.regjeringen.no/contentassets/915655269bc04a47928fce917e4b25f5/handlingsplan-antibiotikaresistens.pdf. Accessed 21 Mar 2016.
Norwegian Directorate of Health. Norwegian National Clinical Guideline for Antibiotic Use in Hospitals. 2013. https://helsedirektoratet.no/retningslinjer/antibiotika-i-sykehus. Accessed 3 Jan 2016.
Cochrane Effective Practice and Organisation of Care (EPOC). Interrupted time series (ITS) analyses. EPOC Resources for review authors. 2017. http://epoc.cochrane.org/sites/epoc.cochrane.org/files/public/uploads/Resources-for-authors2017/interrupted_time_series_analyses.docx. Accessed 13 Oct 2017.
Associates in Process Improvement. Model for Improvement. 2018. http://www.apiweb.org/. Accessed 19 Feb 2018.
World Medical Association. World medical association declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191–4. CrossRef
- The effect of antibiotic stewardship interventions with stakeholder involvement in hospital settings: a multicentre, cluster randomized controlled intervention study
Jannicke Slettli Wathne
Lars Kåre Selland Kleppe
Hege Salvesen Blix
Roy M. Nilsen
The Bergen Intervention Teams
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