Stewardship project in U.K. hospitals reduced average antibiotic dose duration at one year
The intervention included a decision aid that prompted clinicians prescribing antibiotics to classify inpatients' infection risk as possible or probable and then choose between stopping or continuing the prescription at 48 to 72 hours. They also received audit and feedback.
An intervention to encourage inpatient prescribers to discontinue unnecessary antibiotics reduced antibiotic dose duration in a large British trial.
The Antibiotic Review Kit (ARK) was a four-component intervention implemented in a stepped-wedge, cluster-randomized manner. The intervention included a decision aid embedded in the hospital prescription process that prompted clinicians to clarify the level of diagnostic uncertainty at antibiotic initiation by classifying infection risk as possible or probable and then to either stop or continue the prescription at 48 to 72 hours. The other three components were online training to motivate and support use of the decision aid; implementation guidance, including audit and feedback tools; and a patient leaflet. Results were published by The Lancet Infectious Diseases on Oct. 4.
After three British hospitals piloted the intervention, 43 additional sites were randomized to different implementation dates. Seven sites dropped out, so a total of 39 were followed for at least 14 months. The study found no immediate effect of the intervention on the co-primary outcome of doses of antibiotic per acute general medical admission in a month, but after adjustment, there was an a decrease in this outcome on average (−4.8% per year; 95% CI, −9.1% to −0.2%). The other primary outcome was 30-day mortality, which showed an immediate decrease after implementation (−2.7%; 95% CI, −5.7% to 0.3%) but then a sustained increase of 3.0% (95% CI, −0.1% to 6.2%), which the study authors attributed to the pandemic.
“That the intervention changed prescribing over time rather than suddenly might be expected, given the different components, including training for use of the novel decision aid and audit and feedback to re-enforce learning. The change over time could also reflect increasing acceptance that completion of arbitrary antibiotic courses might not reduce risk of resistance,” they wrote.
The authors noted that their program materials are freely available. “Acute hospital providers should consider embedding the ARK-Hospital toolkit in their staff training, prescribing processes, and stewardship work to reduce antibiotic overuse in acute general medical inpatients and protect these patients from antibiotic-related harms,” they wrote.
