Review
Antibiotic prescribing in hospitals: a social and behavioural scientific approach

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Summary

Antibiotics have dramatically changed the prognoses of patients with severe infectious diseases over the past 50 years. However, the emergence and dissemination of resistant organisms has endangered the effectiveness of antibiotics. One possible approach to the resistance problem is the appropriate use of antibiotic drugs for preventing and treating infections. This Review describes how the volume and appropriateness of antibiotic use in hospitals vary between countries, hospitals, and physicians. At each specific level—cultural, contextual, and behavioural—we discuss the determinants that influence hospital antibiotic use and the possible improvement strategies to make it more appropriate. Changing hospital antibiotic use is a challenge of formidable complexity. On each level, many determinants play a part, so that the measures or strategies undertaken to improve antibiotic use need to be equally diverse. Although various strategies for improving antibiotic use are available, a programme with activities at all three levels is needed for hospitals. Evaluating these programme activities in a way that provides external validity of the conclusions is crucial.

Introduction

The advent of antibiotics, which are some of the most successful drugs in medicine, dramatically altered the prognoses of patients with bacterial infections. Their power in both therapy and prophylaxis was so convincing that many older antibiotics have never undergone controlled clinical trials. However, the excessive and indiscriminate use of these so-called miracle drugs in both human and veterinary practices has led to the emergence and dissemination of resistant organisms that endanger their efficacy.1 Major problems are encountered for an increasing number of pathogens, including Staphylococcus aureus, Streptococcus pneumoniae, and Clostridium difficile. For example, the use of almost any antimicrobial drug has the potential to induce the onset of C difficile infection. As a consequence, C difficile infection is the leading cause of hospital-acquired infections in most high-income countries, and resistance is an increasing problem.2, 3, 4, 5

Resistant pathogens cause infections associated with greater mortality and morbidity.6 Antibiotic resistance has a substantial economic impact because of the need for more expensive second-line drugs and longer hospital stays associated with therapy failure.7 Some studies suggest a relation between resistance rates and the volume of antibiotic use.8, 9, 10 In addition, modelling studies show the value of infection-control practices and restricted use of antibiotics to control meticillin-resistant S aureus in hospitals.11, 12 Similarly, the quality of both infection-control practices and antibiotic use plays a part in the incidence of C difficile infection.13, 14 One way of tackling resistance is to use antibiotics appropriately to prevent and treat infections.

Section snippets

Appropriate antibiotic use in hospitals

Appropriate antibiotic use in hospitals entails finding a middle road between their potent ability to reduce the mortality and morbidity of patients with infectious diseases and their potentially hazardous effects (ie, serious adverse events, drug interactions, and induction of resistant strains). Unnecessary use of antimicrobial agents, and use of the newest, broad-spectrum antibiotics when narrow-spectrum and older agents would suffice can lead to increases in resistance, harm patients, and

Research

Historically, the ability to prescribe antibiotics changed the therapeutic power of physicians in an unprecedented fashion. Although antibiotics have lost much of their glamour due to the increasing antimicrobial resistance of microorganisms, this sense of power probably still underlies antibiotic prescription. Thus, changing prescribing habits in hospitals can be a challenge. Unfortunately, a rather naive approach to changing professional behaviour is often used to meet this challenge.22

Cultural aspects

Cars and colleagues30 obtained data about antibiotic drug sales for 1997 and clearly showed the huge variation in antibiotic use in European countries. Dutch antibiotic use was the lowest in Europe; French use was four times greater (the highest in Europe); Belgian and Italian use were three times greater; and German use was 1·5 times greater. The relative numbers of prescriptions varied, as did the extent to which broad-spectrum and newer antibiotics were being prescribed. Hospital sales

Contextual aspects

The way in which individual hospitals organise patients' care also influences their antibiotic prescribing. Schouten and colleagues40 show wide variation between hospitals in nine aspects, or quality indicators, of appropriate antibiotic use at eight medium-sized Dutch hospitals (table). Dedier and colleagues41 describe similar results in their study of antibiotic use in 38 US university hospitals. The proportion of patients receiving antibiotics within 8 h of hospital admission was 53·8–100%

Behavioural aspects

The third level of determinants of hospital antibiotic use is that of individual professionals. Differences in antibiotic use between professionals (within the same hospital or at different hospitals) have not been described. In general, large gaps exist between the care recommended in guidelines and the care provided in daily practice,19, 22, 71 with variation between and within organisations.72 Several studies have quantitatively shown how professional background or clinical experience can

Conclusions

Improving appropriate antibiotic use in hospitals is crucial for the containment of resistance. A focus on novel drug development is also imperative,28 particularly because the average time from inception to market is more than 13 years.

In this Review, we have not discussed patients' views with regard to antibiotic prescribing. Research in general practice has provided insight into the major influence of patients' knowledge and behaviour about antibiotic use in the community. Knowledge of the

Search strategy and selection criteria

We searched Medline for English-language articles on the determinants of variation in hospital antibiotic use in the period January, 1990, to March 11, 2009, inclusive. We combined keywords (non-MeSH) on variation (variation*; determinant*; factor*; difference*; barrier*; cultural; organisational; organizational; individual; all in Title) with antibiotic use (antibiotic*; antibacterial*; antimicrobial*; all in Title). We also reviewed the reference lists of the included papers. This

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