John: Hello, I'm John Hilton, editor of the Cochrane Editorial unit. Antibiotics are a mainstay of hospital care, widely used to treat bacterial infections, such as pneumonia. However amidst increasing concerns about antibiotic resistance, it’s important to ensure that they are prescribed carefully. In February 2017, Peter Davey from the University of Dundee in the UK and colleagues updated their Cochrane Review of interventions to help with this and he tells us more in this Evidence Pod.

Peter: Antibiotic resistance has become a major public health problem because it means that some infections are no longer treatable using currently available drugs. Infections caused by antibiotic-resistant bacteria lead to longer hospital stays and carry a higher risk of death. Inappropriate use of antibiotics is associated with the increase of resistance, and it’s been found that physicians in hospital are not prescribing antibiotics properly about half the time. Our Cochrane Review is an attempt to help with this, bringing together the evidence on interventions to improve how physicians prescribe antibiotics to hospital inpatients.
We identified a total of 221 studies, which had used a variety of research designs to test interventions aimed at healthcare professionals who prescribe antibiotics to hospital in-patients receiving acute care or undergoing planned surgery. The interventions broadly fell into two categories. ‘Restrictive’ techniques applied rules to make physicians prescribe properly, whilst ‘enabling’ techniques provide advice or feedback to help physicians make more informed prescribing decisions. In both cases the aim was to increase the number of appropriate prescribing decisions so that patients who were unlikely to benefit from antibiotics did not get them, whilst they were still given to patients who stood to benefit from them.
We found high quality evidence from 29 randomised trials in more than 23,000 inpatients that following either of these types of intervention, 58% of hospital in-patients received treatment in line with prescribing guidelines, compared with 43% of the patients in the standard practice groups. The interventions probably lead to less antibiotic use, and reduce hospital stay from an average of 13 days to 12 days per patient. Data from 28 randomised trials in nearly 16,000 patients showed that the risk of death was 11% in both treatment groups, suggesting that reducing the antibiotic use did not lead to an increase in harm. While data from 26 studies showed that the interventions were associated with reduction in hospital infections.
Interventions that included enabling or restrictive techniques were consistently more effective than interventions that relied on simple education, such as meetings or distribution of guidelines, alone. Moreover, adding enabling techniques increased the effectiveness of restrictive techniques and the most effective of these were goal-setting, feedback, and action planning.
In summary, our review shows that a wide variety of different interventions have been successful in safely reducing unnecessary antibiotic use in hospitals. Looking to the future, we don’t need more studies to answer the basic question of whether these interventions reduce unnecessary antibiotic use. They clearly do. However, we do need more research to understand why the most effective behaviour change techniques are not more widely adopted within hospital settings. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. Adoption of the interventions we have studied in this review could have considerable impact on health service, policy and future decision-making for millions of patients.

John: If you would like more detail on the interventions in Peter’s review, just go to Cochrane Library dot com and run a simple search for ‘antibiotics in hospital’ to call it up.