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Situation-specific policies can reduce antibiotic resistance in hospital and community care

Wiley

The mass use of antibiotics has caused a rise of bacterial resistance to these drugs that is threatening to destroy the power of these life saving drugs. Two separate systematic reviews published this week in The Cochrane Library show how appropriate interventions in hospitals and doctors' offices can result in improvements in the ways doctors prescribe antibiotics and may lead to a reduction in resistant bacteria.

In hospitals

A systematic review of 66 different studies showed that improving the way that antibiotics are prescribed in hospital to inpatients can reduce antibiotic resistance and hospital acquired infection¹.

The Cochrane Review Authors divided interventions into those that sought to educate or persuade staff to change their prescribing behaviour, and those that imposed a restrictive set of guidelines or orders. An example of this is that some interventions restricted the range of antibiotics that physicians in the hospital could prescribe, while other persuasive interventions got hospital pharmacists to recommend alternative antibiotics to those initially requested.

Other examples of frequently used persuasive techniques were various forms of lectures, seminars and case reviews with all grades of medical and nursing staff.

The authors found that restrictive interventions had a greater immediate impact than persuasive interventions. "But hospitals should resist the temptation to adopt restrictive interventions without evaluating their long-term effects, particularly on clinical outcomes," says lead author Peter Davey who works at Ninewells Hospital and Medical School, Dundee.

"Interestingly, we found that interventions are less likely to be successful if there is evidence that practice is already changing in the desired direction," says Davey.

In Doctors' Offices

A systematic review of 39 studies showed that attitudes towards prescribing were most powerfully changed if the intervention aimed to take account of local situations at the same time as educating prescribing physicians and patients ². Indeed more complex interventions including one-on-one meetings with physicians, small group discussions or combinations of approaches were more likely to have an effect on reducing the misuse of antibiotics.

The simple, single intervention studies, such as handing out printed materials, or holding lectures without any time for in-depth discussion, had only small impact. "Simply drawing a physician's attention to the problem, or even recommending an alternative behaviour, may not provide the tools required to change that behaviour if it is ingrained or multi-factorial," says lead Cochrane Review Author Sandra Arnold, Assistant Professor of Pediatrics at the University of Tennessee, Le Bonheur Children's Medical Center, Memphis, USA.

In one trial, information given in an on-line prescription writer had a positive influence in reducing the number of patients receiving long courses of antibiotics for otitis media (common cause of ear ache in children), although a similar approach to influencing prescribing in streptococcal pharyngitis (sore throats) was less successful.

Multi-faceted interventions involving physicians, patients and community education consistently produced moderate changes in prescribing behaviours.

"If one is attempting to reduce the use of antibiotics for certain conditions such as viral respiratory tract infections, handing out a prescription that can only be used a few days later may be an effective intervention with low cost and great appeal to physicians who feel they are frequently pressured for antibiotics," says Arnold. It appears that this in itself can be a useful form of education, in that patients who see that an illness goes away without treatment are less likely to seek medical help for similar problems in the future.

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Notes to the Editor:

1. Davey P et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. The Cochrane Database of Systematic Reviews 2005, Issue 4.

2. Arnold SR et al. Interventions to improve antibiotic prescribing practices in ambulatory care. The Cochrane Database of Systematic Reviews 2005, Issue 4.

3. The Cochrane Library contains high quality health care information, including Systematic Reviews from The Cochrane Collaboration. These reviews bring together research on the effects of health care and are considered the gold standard for determining the relative effectiveness of different interventions. The Cochrane Collaboration (www.cochrane.org) is a UK registered international charity and the world's leading producer of systematic reviews. It has been demonstrated that Cochrane Systematic Reviews are of comparable or better quality and are updated more often than the reviews published in print journalsª.

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