Peter Davey

Antibiotic stewardship interventions are being implemented across different healthcare settings. We report the findings of a global survey of healthcare professionals on the implementation of antibiotic stewardship programmes. Learners of a Massive Online Open Course (MOOC) on antibiotic stewardship were invited to complete an online survey on the core available organisational resources for stewardship. The categorical variables were analysed using chi-squared test, and Likert questions were analysed using an ordinal regression model. The p-values were considered as two-tailed. Significance was set at p-value of < 0.05. The response rate was 55% (505/920), from 53 countries. The responders were 36% (182) doctors, 26% (130) pharmacists, 18% (89) nurses and 20% (104) other (researchers, students and members of the public). Post-graduate training in infection management and stewardship was reported by 56% of doctors compared with 43% (OR 0.59, 95%CI 0.35–1.00) nurses and 35% (OR 0.39, 95%CI 0.24–0.62) of pharmacists. Hospitals were significantly (83% in teaching hospitals, 79% in regional hospitals, p = < 0.01) more likely to have antibiotic policies, when compared to primary care. A surveillance mechanism for antibiotic consumption was reported in 58% (104/178) of teaching hospitals and 62% (98/159) of regional hospitals. Antimicrobial resistance, patient needs, policy, peer influence and specialty level culture and practices were deemed important determinants for decision-making. Postgraduate training and support in antibiotic prescribing remains low amongst nurses and pharmacists. Whilst antibiotic policies and committees are established in most institutions, surveillance of antibiotic use is not. The impact of specialty level culture, and peer influence appears to be important factors of antibiotic prescribing.

Our aim was to test the feasibility of interprofessional, workplace-based learning about improvement through a 4-week placement for one medical and two pharmacy final year students in an Acute Surgical Receiving Unit (ASRU). The target was insulin because this is a common, high-risk medicine in this ASRU and the intervention was medicines reconciliation. Baseline data were collected from 10 patients and used to construct a cause and effect diagram and a process map through feedback and discussions with staff. Hypoglycaemia occurred in four patients but hyperglycaemia occurred in eight patients, of whom six were placed on intravenous insulin infusion (IVII). We estimated that £2454 could be saved by preventing one patient from going on IVII. The students designed and tested a sticker to improve medicines reconciliation for insulin patients. An online form was created to capture clinician feedback on the layout and usability of the sticker. The intervention was associated with improvements in the reliability of medicines reconciliation. The students’ work contributed to a larger project to reduce the risk of hypoglycaemia in the ASRU. This proved beneficial in enabling the students to engage with the clinical team. Nonetheless, it was challenging for students from two Universities to get a shared understanding of improvement methods and work effectively with the clinical team. The students said that they learnt more about quality improvement in a working healthcare environment than they would ever learn in a classroom and they valued the opportunity to work with students from other healthcare backgrounds in practice. Despite the additional staff time required to support students from two Universities, both have supported continuation of this work.

Investigation of real incidents has been consistently identified by expert reviews and student surveys as a potentially valuable teaching resource for medical students. The aim of this study was to adapt a published method to measure resident doctors’ reflection on quality improvement and evaluate this as an assessment tool for medical students. The design is a cohort study. Medical students were prepared with a tutorial in team based learning format and an online Managing Incident Review course. The reliability of the modified Mayo Evaluation of Reflection on Improvement tool (mMERIT) was analysed with Generalizability G-theory. Long term sustainability of assessment of incident review with mMERIT was tested over five consecutive years. A total of 824 students have completed an incident review using 167 incidents from NHS Tayside’s online reporting system. In order to address the academic practice gap students were supervised by Senior Charge Nurses or Consultants on the wards where the incidents had been reported. Inter-rater reliability was considered sufficiently high to have one assessor for each student report. There was no evidence of a gradient in student marks across the academic year. Marks were significantly higher for students who used Section Questions to structure their reports compared with those who did not. In Year 1 of the study 21 (14%) of 153 mMERIT reports were graded as concern. All 21 of these students achieved the required standard on resubmission. Rates of resubmission were lower (3% to 7%) in subsequent years. We have shown that mMERIT has high reliability with one rater. mMERIT can be used by students as part of a suite of feedback to help supplement their self-assessment on their learning needs and develop insightful practice to drive their development of quality, safety and person centred professional practice. Incident review addresses the need for workplace based learning and use of real life examples of mistakes, which has been identified by previous studies of education about patient safety in medical schools.

This protocol was written with the express purpose of updating the methodology for the review, and has now been superseded by the updated review (Davey 2017).

Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias. More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention. The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence). Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence). There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomes We analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions. Interventions visant à améliorer les pratiques de prescription d'antibiotiques aux patients hospitalisés La résistance aux antibiotiques est un problème majeur de santé publique. Les infections causées par des bactéries multirésistantes sont associées à une prolongation des hospitalisations et à une surmortalité par rapport à celles causées par des bactéries sensibles. L’utilisation appropriée des antibiotiques dans les hôpitaux devrait assurer le traitement efficace des patients souffrant d’une infection et réduire les prescriptions inutiles. Nous avons actualisé cette revue systématique afin d’évaluer l'impact des interventions visant à améliorer la prescription d’antibiotiques aux patients hospitalisés. Évaluer l'efficacité et l'innocuité des interventions visant à améliorer la prescription d'antibiotiques aux patients hospitalisés et étudier l'effet de deux approches de l’intervention : la restriction et la facilitation. Nous avons effectué des recherches dans le registre Cochrane des essais contrôlés (CENTRAL) (la Bibliothèque Cochrane), MEDLINE et Embase. Nous avons recherché des études supplémentaires en utilisant les bibliographies des articles inclus et des fichiers personnels. La dernière recherche dans laquelle des données ont été évaluées et des études identifiées et incorporées dans la revue remontait à janvier 2015. Nous avons inclus des essais contrôlés randomisés (ECR) et des études non randomisées (ENR). Nous avons inclus trois études non randomisées afin de mesurer des paramètres cliniques et comportementaux et d’analyser les variations des effets : essais non randomisés (ENR), études contrôlées avant-après (CAA) et séries temporelles interrompues (STI). Pour cette mise à jour, nous avons également inclus trois autres études non randomisées (études cas-témoin, de cohorte et qualitatives) afin d'identifier des conséquences imprévues. Les interventions incluaient toute intervention professionnelle ou structurelle suivant la définition du groupe de travail Cochrane sur l'efficacité des pratiques et l'organisation des soins. Nous avons défini la restriction comme « l’utilisation de règles pour réduire la possibilité de pratiquer le comportement visé (ou d’amplifier ce comportement en réduisant la possibilité d’adopter des comportements concurrents) ». Nous avons défini la facilitation comme « l’augmentation des moyens ou la réduction des obstacles pour accroître la capacité ou les occasions ». La comparaison principale a été effectuée entre les groupes d'intervention et sans intervention. Deux auteurs de la revue ont extrait les données et évalué le risque de biais des études. Nous avons effectué une méta-analyse et une méta-régression des ECR et des STI. Nous avons classé les fonctions de changement des comportements pour toutes les interventions de la revue, y compris celles incluses dans les versions publiées précédemment. Nous avons analysé les données dichotomiques avec une différence de risque (DR) et évalué la qualité probante des données à l’aide des critères GRADE. Cette revue inclut 221 études (58 ECR et 163 ENR). La plupart des études ont été réalisées en Amérique du Nord (96) ou en Europe (87), les autres en Asie (19), en Amérique du Sud (8), en Australie (8) et en Asie du Sud-Est (3). Bien que 62 % des ECR aient présenté un risque élevé de biais, les résultats de la revue pour les principaux critères d’évaluation étaient similaires lorsque nous avons limité l'analyse aux études à faible risque de biais. Avec les interventions, un plus grand nombre de patients hospitalisés ont été traités conformément aux règles de prescription d'antibiotiques que sans l’intervention, selon les données de 29 ECR concernant principalement des interventions facilitatrices (DR 15 % ; intervalle de confiance (IC) à 95 % de 14 % à 16 % ; 23 394 participants ; niveau élevé de certitude des preuves). Cela représente une augmentation de 43 % à 58 %. La taille de l’effet était fortement hétérogène mais, en tendance, largement en faveur de l'intervention. La durée du traitement antibiotique a diminué de 1,95 jour (IC à 95 % de 2,22 à 1,67 ; 14 ECR, 3318 participants ; niveau élevé de certitude des preuves) à partir de 11,0 jours. Les informations issues d'études non randomisées ont montré que les interventions étaient associées à une amélioration de la prescription d'antibiotiques conformément aux procédures dans la pratique clinique courante, avec 70 % des interventions étendues à tout l'hôpital contre 31 % dans les ECR. Le risque de décès était similaire entre les groupes d'intervention et témoin dans les deux bras (11 %), ce qui indique que l'utilisation d'antibiotiques a probablement été réduite sans que la mortalité en soit affectée négativement (DR 0 %, IC à 95 % de -1 % à 0 % ; 28 ECR, 15 827 participants ; niveau modéré de certitude des preuves). Les interventions de gestion des antibiotiques ont probablement réduit la durée des séjours de 1,12 jour (IC à 95 % de 0,7 à 1,54 jours ; 15 ECR, 3834 participants ; niveau modéré de certitude des preuves). Un ECR et six ENR ont soulevé des inquiétudes quant au fait que les interventions restrictives pourraient conduire à un retard dans le traitement et une dégradation de la culture professionnelle en affectant la communication et la confiance entre les spécialistes des infections et les équipes cliniques (niveau faible de certitude des preuves). La facilitation et la restriction sont associées, de façon indépendante, à une augmentation du respect des directives de traitement antibiotique, et la facilitation a amélioré l’effet des interventions restrictives (niveau élevé de certitude des preuves). Les interventions facilitatrices incluant un retour d'information ont probablement été plus efficaces que celles qui n’en comportaient pas (niveau modéré de certitude des preuves). Nous avons trouvé des preuves d'un niveau faible de certitude concernant l'effet des interventions sur la réduction des infections à Clostridium difficile (médiane de -48,6 %, intervalle interquartile de -80,7 % à -19,2 % ; 7 études) et sur les infections par des bactéries résistantes à Gram négatif (médiane de -12,9 %, intervalle interquartile de -35,3 % à 25,2 % ; 11 études) et à Gram positif (médiane de -19,3 %, intervalle interquartile de -50,1 % à +23,1 % ; 9 études). Il y avait trop de variations dans les paramètres microbiologiques pour évaluer de manière fiable l'effet du changement dans l'usage des antibiotiques. Hétérogénéité de l'effet de l'intervention sur les critères d’évaluation concernant les prescriptions Nous avons analysé les facteurs modifiant l’effet dans 29 ECR et 91 études de STI. La facilitation et la restriction ont été associées de manière indépendante à une plus grande taille d’effet (niveau élevé de certitude des preuves). Un retour d'information était inclus dans 4 (17 %) des 23 ECR et 20 (47 %) des 43 études de STI concernant des interventions facilitatrices et était associé à un plus grand effet des interventions. Une facilitation a été incluse dans 13 (45 %) des 29 études de STI de méthodes restrictives et a renforcé l’effet de ces interventions. Nous avons trouvé des preuves de bonne qualité que les interventions étaient efficaces pour augmenter le respect des directives de traitement antibiotique et réduire la durée des antibiothérapies. La réduction de l'utilisation des antibiotiques n’a pas semblé augmenter la mortalité et a probablement réduit la durée des hospitalisations. Des essais supplémentaires destinés à comparer la gestion des antibiotiques à l'absence d'intervention sont peu susceptibles de modifier nos conclusions. La facilitation a constamment renforcé l'effet des interventions, y compris celles comportant une composante restrictive. Bien que le retour d'information ait encore augmenté l'effet de l'intervention, il n’a été utilisé que dans une minorité des interventions facilitatrices. Les interventions étaient efficaces pour réduire, en toute sécurité, l'utilisation excessive des antibiotiques dans les hôpitaux, malgré le fait que la majorité d'entre elles n'utilisaient pas les méthodes les plus efficaces de modification des comportements. Par conséquent, une diffusion efficace de nos résultats pourrait avoir un impact considérable sur les politiques et services de santé. Les recherches futures devront plutôt se concentrer sur le ciblage des traitements et évaluer d’autres mesures de la sécurité des patients, examiner différentes interventions de gestion et étudier les obstacles et les facteurs favorables à la mise en place des interventions. Des recherches supplémentaires sont également nécessaires sur les conséquences imprévues des interventions restrictives. Traduction réalisée par Suzanne Assénat et révisée par Cochrane France

The pressing need to measure and improve antibiotic use was recognized >40 years ago, so why have we failed to achieve sustained improvement at scale? In his 2014 Reith Lectures about the future of medicine, the US surgeon Atul Gawande said that failure in medicine is largely due to ineptitude (failure to use existing knowledge) rather than ignorance (lack of knowledge). Consequently, it is notable that most interventions to improve antimicrobial prescribing are either designed to educate individual practitioners or patients about policies or to restrict prescribing to make practitioners follow policies. Interventions that enable practitioners to apply existing knowledge through decision support, feedback and action planning are relatively uncommon. There is an urgent need to improve the design and reporting of interventions to change behaviour. However, achieving sustained improvement at scale will also require a more profound understanding of the role of context. What makes contexts receptive to change and which elements of context, under what circumstances, are important for human performance? Answering these questions will require interdisciplinary work with social scientists to integrate complementary approaches from human factors and ergonomics, improvement science and educational research. We need to rethink professional education to embrace complexity and enable teams to learn in practice. Workplace-based learning of improvement science will enable students and early-career professionals to become change agents and transform training from a burden on clinical teams into a driver for improvement. This will make better use of existing resources, which is the key to sustainability at scale.

Bacteriuria is not a disease; it is a laboratory finding. Tests for bacteriuria do not establish the diagnosis of urinary tract infection, which should be based on symptoms and signs. Treatment of asymptomatic bacteriuria is indicated only in children and pregnant women. The main value of urine culture is to identify the bacteria responsible for an infection and their sensitivity to antibiotics. Urine dipstick tests have a very limited role in the diagnosis of urinary tract infection. They are not sufficiently accurate to be used for screening of asymptomatic bacteriuria in pregnancy and are only helpful in the management of patients who do not have clear symptoms of lower urinary tract infection. Trimethoprim for three days is the treatment of choice for uncomplicated urinary tract infections with nitrofurantoin as second choice in women who have received trimethoprim or co-trimoxazole in the previous three months.