Controlling antibiotic-prescribing practices in hospitals

Oct 18 2005

Plenty of promising strategies exist to control antibiotic-prescribing practices, but no single method emerges as the best for hospital patients, according to a new review of studies.

Antibiotics combat bacterial infections, like strep throat. But its overuse has been tied to a rise in organisms that build a resistance to the drugs.

The systematic review of data from 66 studies appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

Most of the studies were conducted at a single hospital -- one of the main factors that prevented the researchers from drawing meaningful conclusions about the benefits of individual interventions. Also, none of the studies compared one intervention to another, so it was impossible to identify a superior approach.

"What might work in one hospital, won't necessarily work in another," said Erwin Brown, M.D., a medical microbiologist on the review team. "The literature wasn't sufficiently robust for us to say: 'This works or this doesn't.'"

Ralph Gonzales, M.D., an associate professor of medicine at the University of California, San Francisco, said antibiotic resistance is an especially critical problem in hospitals.

Each antibiotic is effective only against certain bacteria -- the organisms that cause infection. Often it takes a physician's best guess, laboratory tests and time to pinpoint the bacteria responsible for an illness.

"The chances are extremely low that an ambulatory-care patient will die because they don't get the correct antibiotic. That chance is greater for a critical-care patient in a hospital," Gonzales said.

Gonzales, who was not involved in the Cochrane review, has worked in the United States to craft guidelines for antibiotics prescribing. "It's important to pick the most tailored, narrow-spectrum antibiotic," he said.

There are many campaigns -- and generally agreed-on approaches -- to change antibiotic prescribing practices in community health centers and doctor's offices. But Gonzales said similar coordinated campaigns or agreements have lagged for hospitals.

Drug-resistance problems differ from hospital to hospital, Gonzales said. Each hospital has its own culture, he said, so the best resistance-reduction strategy may be linked to each facility's prescribing problems and goals.

In the Cochrane review, most of the interventions studied fell into one of two strategy groups: "persuasive" or "restrictive." Persuasive interventions included education meetings and verbal reminders. Restrictive interventions included automatic stop orders for certain antibiotics or required preauthorization from an infectious-disease specialist for some drugs.

The reviewers looked at how the interventions affected three different kinds of outcomes. Drug outcomes included whether or not a doctor prescribed an antibiotic, drug choice and dosage. Clinical outcomes measured the length of patient hospital stays, readmission and mortality rates. The reviewers also analyzed microbiological outcomes to determine whether an intervention affected the incidence of drug-resistant organisms commonly contracted in hospitals.

Seventy-seven percent (51) of the 66 studies showed a significant improvement in at least one outcome. "The results show that interventions to improve antibiotic prescribing to hospital inpatients are successful, and can reduce antimicrobial resistance or hospital acquired infections," the reviewers say.

While the Cochrane review looked at drug, clinical and microbiological outcomes across the 66 studies, only one study provided information on all three outcomes.

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