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
ReviewAntibiotic prescribing in hospitals: a social and behavioural scientific approach
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
References (80)
- et al.
Infections caused by Gram-positive bacteria: a review of the global challenge
J Infect
(2009) - et al.
Modelling and forecasting antimicrobial resistance and its dynamic relationship to antimicrobial use: a time series analysis
Int J Antimicrob Agents
(2000) - et al.
Antimicrobial drug use and infection control practices associated with the prevalence of methicillin-resistant Staphylococcus aureus in European hospitals
Clin Microbiol Infect
(2007) - et al.
From best evidence to best practice: effective implementation of change in patients' care
Lancet
(2003) - et al.
Variation in antibiotic use in the European Union
Lancet
(2001) - et al.
Scientific versus commercial sources of influence on the prescribing behavior of physicians
Am J Med
(1982) - et al.
An international survey of practice variation in the use of antibiotic prophylaxis in cesarean section
Int J Gynecol Obstet
(2001) - et al.
Use of antibiotics in hospitals in south-western France
J Hosp Infect
(2004) - et al.
Variations in antimicrobial use and cost in more than 2,000 patients with community-acquired pneumonia
Am J Med
(1998) - et al.
A multidisciplinary approach to antimicriobial stewardship: evolution into the 21st century
Intern J Antimicrob Agents
(2005)