SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
October, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
In-hospital infections caused by antibiotic-resistant bacteria and Clostridium difficile are associated with higher rates of death, illness and prolonged hospital stay which is a serious problem for patients and healthcare systems. These infections occur because antibiotics are used too often and incorrectly.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Antibiotic usage in hospitals is increasing and over a third of prescriptions are not compliant with evidence-based guidelines. One of the consequences, besides worse patient outcomes, is antimicrobial resistance which is considered a major public health problem in terms of health outcomes and costs. This review assessed the effects of professional interventions in antibiotic stewardship for hospital inpatients.
‘Antibiotic stewardship’ is used to capture the twin aims of ensuring effective treatment of patients with infection and minimizing collateral damage from antimicrobial use through appropriate antibiotic prescribing. The interventions were classified as: persuasive (dissemination of educational materials in printed form or via educational meetings reminders, audit and feedback, educational outreach); restrictive (financial and healthcare system changes as compulsory order form, expert approval, removing restricted antibiotics from drug cupboards, changing of prescription by reviewers); and structural (new technology for laboratory testing or computerized decision support).
| Review objectives:To assess the effectiveness of professional interventions that, alone or in combination, are effective in antibiotic stewardship for hospital inpatients. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies of interventions directed to antibiotic stewardship |
89 included studies (95 interventions): 25 randomised trials, 3 non-randomised trials, 5 controlled before-after studies, and 56 interrupted time series studies. 84% of the interventions targeted the antibiotic prescribed and the remaining 16% aimed to change exposure of patients to antibiotics by targeting the decision to treat or the duration of treatment. |
| Participants | Healthcare professionals who prescribe antibiotics to hospital inpatients |
Interventions were delivered by multidisciplinary teams (39%), specialist physicians in infectious diseases or microbiology (33%), pharmacists (20%), and department physicians (8%). |
| Settings | Hospital settings worldwide |
USA (48), UK (12), Netherlands (6), Canada (4), Switzerland (3), Australia (3), Thailand (2), Colombia (2), France (2), Germany (2), Spain (2), Israel (2), Austria (1), Belgium (1), Brazil (1), Hong Kong (1), Italy (1), Norway (1), and Sweden (1) |
| Outcomes | Antibiotic prescribing process measures (decision to treat, choice of drug, dose, route or duration of treatment); clinical outcome measures (mortality, length of hospital stay); microbial outcome measure (colonization or infection with clostridium difficile or antibiotic-resistant bacteria) |
Appropriate prescribing of antibiotics, microbial outcomes, patient outcomes (mortality), length of stay, readmissions |
| Date of most recent search: February 2009 | ||
| Limitations: This is a well-conducted systematic review with only minor limitations. | ||
Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews 2013; 4:CD003543.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
89 studies were included. Of the 95 interventions reported in these studies, 79 aimed to decrease excessive antibiotic use, 11 aimed to increase effective treatment and 5 aimed to reduce inappropriate antibiotic use but did not distinguish between excessive and ineffective use.
Appropriate prescribing of antibiotics was assessed by 53 indirect comparisons from 40 studies and microbial outcomes by 20 indirect comparisons from 14 studies.
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Restrictive versus persuasive interventions to improve antibiotic prescribing |
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People Healthcare professionals Settings Secondary care (inpatients in acute, not long term care only) Intervention Restrictive interventions (compared to usual care in studies)† Comparison Persuasive interventions (compared to usual care in studies)† |
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Outcomes |
Impact (percent change in level) |
Certainty of the evidence (GRADE) |
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Appropriate prescribing of antibiotics |
The change was 32% larger for restrictive interventions at one month (95% CI 2 to 61%) compared to persuasive interventions and there was little or no difference at 6, 12, and 24 months. |
Low† |
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Microbial outcomes (colonization or infection with Clostridium difficile or antibiotic-resistant bacteria) |
The change was 53% larger for restrictive interventions at 6 months (95% CI 31 to 75%) compared to persuasive interventions and there was little or no difference at 12 and 24 months. |
Low† |
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GRADE: GRADE Working Group grades of evidence (see above and last page) † Indirect comparison between studies that provide data about effect of either persuasive or restrictive interventions |
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Mortality was assessed by 11 comparisons from 11 studies; length of stay by six comparisons from six studies and readmissions by five comparisons from five studies.
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Interventions intended to decrease unnecessary antibiotic prescribing |
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People Healthcare professionals Settings Secondary care (inpatients in acute, not long term care only) Intervention Interventions intended to decrease unnecessary antibiotic prescribing Comparison Usual care |
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Outcomes |
Impact |
Certainty of the evidence (GRADE) |
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All-cause mortality |
Risk ratio for intervention versus control 0.92 (95% CI 0.81 to 1.06) |
Moderate |
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Length of stay |
Difference (in days) for intervention versus control -0.04 days (95% CI - 0.34 to 0.25) |
Very low |
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Readmissions |
Risk ratio for intervention versus control 1.26 (95% CI 1.02 to 1.57) |
Very low |
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GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Mortality was assessed by four comparisons from four studies.
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Interventions intended to increase effective antibiotic prescribing for pneumonia |
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People Healthcare professionals Settings Secondary care (inpatients in acute care only) Intervention Interventions intended to increase effective antibiotic prescribing for pneumonia Comparison Usual care |
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Outcomes |
Impact |
Certainty of the evidence (GRADE) |
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Mortality |
Risk ratio for intervention versus control 0.89 (95% CI 0.82 to 0.97) |
Low |
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GRADE: GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| None of the included studies were conducted in a low-income country. |
When assessing the transferability of these findings to low-income countries the following factors should be considered: − The availability of resources specially for persuasive and structural interventions − The acceptability and costs of the interventions Locally tailored up to date antibiotic treatment guidelines |
| EQUITY | |
| There was no information in the included studies regarding differential effects of the interventions on resource-disadvantaged populations. |
Resources needed for interventions may be less available in disadvantaged settings. The interventions may increase inequity if they are not applied or adapted to these populations. |
| ECONOMIC CONSIDERATIONS | |
| Limited data showed that savings exceeded the cost of the intervention in 8 out of 10 studies. |
Scaling up many of the interventions will require resources, that should be considered. Local costing should be undertaken, particularly in settings differing from the original investigations. |
| MONITORING & EVALUATION | |
| There is evidence that interventions to improve antibiotic prescribing for pneumonia may decrease mortality. No clear evidence of benefit and safety was found for other outcomes. |
Future studies should provide information about the resources required for development, dissemination and implementation of guidelines and other relevant interventions. Larger and more rigorous studies to determine the effectiveness, safety and cost-effectiveness of interventions are needed, particularly in resource-poor settings. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods |
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Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices. Virulence 2013; 4(2):192-202.
Aryee A, Price N. Antimicrobial stewardship – can we afford to do without it? British Journal of Clinical Pharmacology 2015; 79(2):173-81.
Chung GW, Wu JE, Yeo CL, Chan D, Hsu LY. Antimicrobial stewardship: a review of prospective audit and feedback systems and an objective evaluation of outcomes. Virulence 2013; 4(2):151-7.
Reed EE, Stevenson KB, West JE, et al. Impact of formulary restriction with prior authorization by an antimicrobial stewardship program. Virulence 2013; 4(2):158-62.
Wagner B, Filice GA, Drekonja D, et al. Antimicrobial stewardship programs in inpatient hospital settings: a systematic review. Infection Control and Hospital Epidemiology 2014; 35(10):1209-28.
Chandy SJ, Naik GS, Charles R, et al. The impact of policy guidelines on hospital antibiotic use over a decade: a segmented time series analysis. PloS One 2014; 9(3):e92206.
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Gavin Barlow, Göran Tomson, and Peter Davey.
Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews 2013; 4:CD003543.
Keywords
All Summaries:
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low- and middle- income countries, developing countries, primary health care; antibiotic prescribing, hospital inpatients, antimicrobial stewardship, antibiotic policies, implementation strategies
