Blog | Monday, May 6, 2013

QD: News Every Day--Restrictions change prescribing habits faster than persuasion

When it comes to changing antibiotic prescribing habits, a "stick" approach is useful when an immediate change in prescribing habits is needed, but the "carrot" approach is equally as effective after 6 months, a meta-analysis showed.

A review that appeared in The Cochrane Library updated studies done since December 2006 to a previous review to evaluate the impact of interventions from the perspective of antibiotic stewardship, ensuring effective treatment while reducing unneeded use and minimizing collateral damage.

Researchers culled the published literature for interventions that had a restrictive element that put a limit on how clinicians prescribed, for example, if physicians needed approval from an infection specialist to prescribe an antibiotic. These were compared to purely persuasive methods that advised physicians about how to prescribe or gave them feedback about how they prescribed, such educational resources, reminders, audit and feedback, or educational outreach. Restrictive interventions could contain persuasive elements.

Of 89 studies from 19 countries that met the criteria, 56 were interrupted time series (ITS), of which 4 were controlled ITSs; 25 were randomized controlled trials (RCT), of which 5 were cluster-RCTs; 5 were controlled before-after trials; and 3 were controlled clinical trials (CCT), of which 1 was a cluster-CCT.

There were 95 interventions studied among the trials, of which 80 (84%) targeted the antibiotic prescribed (choice of antibiotic, timing of first dose and route of administration). The remaining 15 interventions targeted the decision to treat or the duration of treatment.

For the 76 persuasive interventions that had reliable data, the median change in antibiotic prescribing was 42.3% for the ITSs, 31.6% for the controlled ITSs, 17.7% for the CBAs, 3.5% for the cluster-RCTs and 24.7% for the RCTs. Restrictive interventions had a median effect size of 34.7% for the ITSs, 17.1% for the CBAs and 40.5% for the RCTs. Structural interventions had a median effect of 13.3% for the RCTs and 23.6% for the cluster-RCTs.

Data about impact on microbial outcomes were available for 21 interventions but only 6 of these also had reliable data about impact on antibiotic prescribing.

Based on results of 52 ITS studies, restrictive interventions had significantly greater impact on prescribing outcomes at one month (32%; 95% confidence interval (CI), 2% to 61%, P=.03) and on microbial outcomes at 6 months (53%; 95% CI, 31% to 75%, P=.001) with no significant differences at 12 or 24 months.

Interventions intended to decrease excessive prescribing were associated with reductions in infections from Clostridium difficile and aminoglycoside- or cephalosporin-resistant gram-negative bacteria, methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis. Four interventions intended to increase effective prescribing for pneumonia were associated with significant reduction in mortality (risk ratio [RR], 0.89; 95% CI, 0.82 to 0.97), whereas nine interventions intended to decrease excessive prescribing were not (RR, 0.92; 95% CI, 0.81 to 1.06).

Researchers concluded, "The results show that interventions to reduce excessive antibiotic prescribing to hospital inpatients can reduce antimicrobial resistance or hospital-acquired infections, and interventions to increase effective prescribing can improve clinical outcome."