A new meta-analysis from a team of Cochrane scientists looked at 221 studies to assess the effectiveness and safety of interventions which try to improve how doctors prescribe antibiotics to in-patients. The analysis also identified ways of reducing unnecessary use of antibiotics in hospitals.

A wide variety of interventions were found to safely reduce unnecessary antibiotic use in hospitals, according to a new update from a meta-analysis which has been running for 15 years.

The update found that in hospitals antibiotics are only prescribed according to medically recommended guidelines 43 per cent of the time. This means that in more than half of the cases where antibiotics were used, hospital doctors prescribed them outside of the guidelines.

When antibiotics are used too often or incorrectly, this leads to the development of resistant bacteria. In Germany it’s estimated that between one and four thousand people die in hospital from antibiotic resistant infections every year.

Why aren’t the doctors following the guidelines?

“Valium for Surgeons”

Many surgeons prescribe antibiotics as a precaution during surgery, says Hajo Grundmann, Head of Hospital Hygiene at the University Hospital of Freiburg. He says that surgeons administer antibiotics as a “reassurance” days after surgery has been completed, in contradiction to the guidelines which says antibiotics should be administered at most a few hours before and after surgery to prevent infection.

Grundmann says that “antibiotics are the valium for surgeons” because they bring peace of mind, but adds that there is another factor: many hospitals are now profitable companies. This puts the doctors under greater pressure. Their performance is measured not just in terms of whether the operations are successful, but whether they’re earning money for the hospital. When it comes to efforts to prescribe antibiotics “sparingly” Grundmann says this may play a role.

The new study also demonstrated that it’s possible to change the prescribing behaviour of doctors through interventions. These can include monitoring, training and supervising doctors when it comes to their use of antibiotics – and according to the study, these interventions can improve appropriate prescribing rates by 15 per cent.

Grundmann says that the difference, from 43 per cent appropriate prescribing without any interventions, to 58 per cent appropriate prescribing with interventions, is great. It’s a clear sign, he says, that it’s possible to change doctors behaviour without medically disadvantaging the patient. The study also showed that prescribing antibiotics within the guidelines could reduce a patient's hospital stay by one day – reducing their chances of picking up an infection in hospital.

But 58 per cent of antibiotic prescribing falling with guidelines still means that a third of antibiotics in hospitals will be prescribed inappropriately. Winfried Kern, Professor of Infectiology at the University Hospital of Freiburg, says that unfortunately it’s not realistic to expect 100 per cent of prescribing to be within the guidelines. There are many medical situations, he says, where there is no guideline or where it would be medically sensible to deviate from the guideline – for example, if a patient is particularly susceptible to a certain antibiotic.

“And more than this, the guidelines are not always that good”, Kern added.

The study was published by a team led by Peter Davey at Dundee University, and looked in detail at how and why different interventions work. Davey said that one problem is that interventions are often vague and unconcrete, and do not have precise objectives. Sometimes the aim is to “follow the guidelines more often”, rather than trying to get appropriate prescribing up to 80 per cent, for example. This makes it difficult to increase appropriate prescribing and difficult to quantify successful interventions.

The least effective kind of intervention, Davey said, was to make doctors fill out a form before they could administer antibiotics to a patient. Often this would make the doctor feel patronised, and they might then fudge the form in order to get the antibiotics for the patient. Training events on antibiotic prescribing were also ineffective, he said.

But in Germany, the focus has been on training. “If something doesn’t work, there is training afterwards”, says Petra Gastmeier, a senior hygienist at the Berlin Charité hospital. There isn’t a lack of knowledge in Germany – the doctors, in theory, know what they are supposed to do.

According to Gastmeier, in the English speaking world more progress has been made. Infection specialists, surgeons and other doctors are often supervised and given feedback on their prescribing behaviour.

Gastmeier is now working on a project in Germany which should also encourage paramedics to prescribe antibiotics more appropriately. The situation in ambulances is similar to that in hospitals, she says.

We investigate multiresistant germs long term: correctiv.org/superbugs. Tips and questions to: hristio.boytchev@correctiv.org.

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