Improving antibiotic prescribing to hospital inpatients
Submitting InstitutionUniversity of Dundee
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Medical Microbiology, Public Health and Health Services
Summary of the impact
The need to measure and improve hospital antibiotic prescribing was
identified as a priority in European and UK policy documents about
antibiotic resistance in the late 1990s. Our research developed
sustainable methods for evaluating interventions to improve hospital
antibiotic prescribing, and led to Davey collaborating with the
European Surveillance of Antimicrobial Consumption (ESAC) project and
becoming the Scottish Antimicrobial Prescribing Group's Representative
with Responsibility for International Liaison and Research. Implementation
of ESAC quality indicators and measurement methods has been associated
with progressive improvement in antibiotic policy compliance and reduction
in Clostridium difficile infection in all 14 Health Boards in
Scotland since 2008.
Following the House of Lords reports on Antimicrobial Resistance in 1998
and 2001 and the European Union's Microbial Threat in 1998, which
expressed extreme concern with the lack of progress in measurement of
antibiotic use and compliance with policies in hospitals (http://www.publications.parliament.uk/pa/ld199798/ldselect/ldsctech/081vii/st0701.htm,
Davey (Lead for Clinical Quality Improvement, Division of
Population Health Sciences, Dundee) collaborated with Ramsay (University
of Aberdeen) and the British Society for Antimicrobial Chemotherapy on a
systematic review [i]. This confirmed significant gaps in the evidence
base on interventions to improve hospital antibiotic prescribing. They
tested a novel approach to measurement of effect size with segmented
regression analysis of an intervention to change antibiotic policy in NHS
Tayside [ii] and used the method in the systematic review to demonstrate a
significant association between reduction in use of broad spectrum
antibiotics and infections with drug resistant bacteria and with C.
difficile [iii]. Collaboration with authors of another systematic
review about infection control produced the ORION guidelines for good
practice in reporting interventions [iv].
Most hospital data systems only record supply of antibiotics to hospital
wards. This information can be used to analyse the impact of interventions
on use of antibiotics targeted by policy change [ii]. However, hospitals
also need a sustainable method for measurement of prescribing to
individual patients in order to assess compliance with antibiotic policy
for treatment of specific infections. Davey was the UK
representative for the 2000-2003 ESAC project and from 2003-10 was funded
by ESAC II and III to lead work on surveillance of hospital consumption.
This led to the development and testing in 20 European hospitals of a
method for point prevalence surveying of the treatment of individual
patients. The participating hospitals conducted the point prevalence
survey without any additional resources for data collection [v]. Analysis
and comparison between hospitals was enabled by a web based reporting
system. The output from this work included identification of three quality
- Documentation of indication for antibiotics in the hospital case notes
- Compliance with the hospital antibiotic policy
- Duration of all antibiotic prophylaxis for surgery no greater than 24h
Following on from the ESAC project Davey collaborated with
colleagues in Geneva on time series analysis of pharmacy data to identify
targets for reduction in C difficile infections. The model for
hospital-acquired C. difficile infections suggested that variation
in four antibiotics explained 61% of the variance in C. difficile
infections in hospitals in NHS Tayside [vi] and led to an intervention to
change antibiotic policy in hospitals in Scotland.
References to the research
i. Ramsay C, Brown E, Hartman G and Davey P (2003) Room for
improvement: a systematic review of the quality of evaluations of
interventions to improve hospital antibiotic prescribing. J.
Antimicrob. Chemother. 52, 764-771 (DOI:
ii. Ansari F, Gray K, Nathwani D, Phillips G, Ogston S, Ramsay C, and Davey
P (2003) Outcomes of an intervention to improve hospital antibiotic
prescribing: interrupted time series with segmented regression analysis. J.
Antimicrob. Chemother. 52, 842-848 (DOI:
iii. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G,
Holmes A, Ramsay C, Taylor E, Wilcox M and Wiffen P (2005) Interventions
to improve antibiotic prescribing practices for hospital inpatients. Cochrane
Database of Systematic Reviews 2013 Issue 4: CD003543 (DOI:
iv. Stone SP, Cooper BS, Kibbler CC, Cookson BD, Roberts JA, Medley GF,
Duckworth G, Lai R, Ebrahim S, Brown EM, Wiffen PJ and Davey, PG
(2007) The ORION statement: guidelines for transparent reporting of
outbreak reports and intervention studies of nosocomial infection. Lancet
Infect. Dis. 7, 282-288 (DOI:10.1016/S1473-3099(07)70082-8).
v. Ansari F, Erntell M, Goossens H and Davey P (2009) The
European surveillance of antimicrobial consumption (ESAC) point-prevalence
survey of antibacterial use in 20 European hospitals in 2006. Clin.
Infect. Dis. 49, 1496-1504 (DOI: 10.1086/644617).
vi. Vernaz N, Hill K, Leggeat S, Nathwani D, Philips G, Bonnabry P and Davey,
P (2009) Temporal effects of antibiotic use and Clostridium
difficile infections. J. Antimicrob. Chemother. 63,
1272-1275 (DOI: 10.1093/jac/dkp128).
• Davey P (lead for Hospital Prescribing Sub-project) with
Goossens (University of Antwerp): European Surveillance of Antimicrobial
Consumption; DG Sanco of the European Union (01/10/2005 to 01/10/2007)
Value to University of Dundee £16,562 (Total grant €3.5M).
• Davey P (lead for Work Packages 4 and 5) with Frank, Schumacher
(University of Freiburg), Grundman (RIVM, Netherlands), Suetens (Institute
of Public Health, Brussels): Burden of Resistance and Disease in European
Nations; DG Sanco of the European Union. (01/07/2007 to 31/07/2009). Value
to University of Dundee £185,256 (Total grant €1.32M).
• Davey P (with Donnan P, University of Dundee):
Monitoring consequences of changes in antibiotic regime for surgical
prophylaxis; Healthcare Associated Infection Task Force, Scottish
Government (01/10/ 2011 to 30/06/2013) £60,227.
• Davey P, (with Marwick C, University of Dundee, Charani
E, Imperial College Gould I, Ramsay C, University of Aberdeen): Systematic
review and meta-analysis of interventions to improve antibiotic
prescribing practices for hospital inpatients; Chief Scientist Office,
Scotland (01/06/2013 to 31/03/2015) £174,906.
Details of the impact
Our research has been central to the development of methods for
evaluating the impact of antibiotic policy and the relationship between
hospital prescribing and resistance in Europe; Davey has, for example,
participated in Europe-wide reviews of the issue [1,2]. In Scotland our
work on prescribing indicators and quality improvement has enabled
sustainable evaluation of hospital antibiotic prescribing by hospitals in
all 14 Health Boards; this was accompanied by a demonstrated 43% reduction
in C. difficile infection in Scotland between 2008 and 2011 [3,p7
In addition to multiple citations of the main report of the Cochrane
review [iii], its impact is evidenced by the ORION guidelines [iv] arising
from subsequent collaboration with researchers from University College
London and the University of Bristol. These have been endorsed by
professional societies in the UK, Europe and USA and disseminated at their
meetings . The Cochrane review was quoted in the Scottish Management of
Antimicrobial Resistance Action Plan (http://www.scotland.gov.uk/Publications/2008/03/12153030/0)
and influenced the recommendation for a national organisation to integrate
improvement in antibiotic prescribing with control of healthcare
associated infection. This resulted in establishment of the Scottish
Antimicrobial Prescribing Group (SAPG) as part of the Scottish Medicines
Consortium (2007) .
Research outputs [i-iv] led to Davey being invited to lead the Hospital
Subproject of ESAC from 2003-2010. From 2006-2010 Davey led the
development and testing in 20 European hospitals of a web based method for
reporting on point prevalence studies of antibiotic use [v]. The ESAC
project continued until 2010 and the ESAC website documents wide
dissemination across Europe. The 2009 point prevalence survey included 172
hospitals from 25 European countries . In Scotland, hospitals from all
14 Health Boards participated in the 2009 ESAC point prevalence survey,
and this is specifically cited by NHS Boards when discussing the impact
SAPG has had in their area, in the SAPG 2009 Annual Report .
As the Representative with Responsibility for International Liaison and
Research for SAPG Davey recommended that the ESAC quality
indicators should be adopted as national targets. This SAPG recommendation
was included by Scottish Government in 2009 as part of their HEAT (Health,
Efficiency and Access to Treatment) target to reduce the rate of C.
difficile Associated Disease among patients aged 65 and over by at
least 30% by 31 March 2011 . SAPG adapted the ESAC Point Prevalence
Survey method for continuous measurement of compliance with the national
targets for hospital antibiotic use. A secure, web based system was
created for all acute hospitals in Scotland to report their compliance
with antibiotic policy with monthly prevalence surveys in acute medical
and surgical admission units. The recommended restrictive antibiotic
policy for reducing C. difficile Associated Disease was based on Davey's
study to identify high risk antibiotics [vi] as well as the Cochrane
review [iii]. The SAPG Report on Progress from 2008-11 cites the
development and measurement of hospital prescribing indicators as being
critical to SAPG's contribution to the 43% reduction in C. difficile
infection seen throughout NHS Scotland by national restriction of
antimicrobials associated with a high risk of C. difficile
infection [3,p7]. SAPG continues to use the hospital antibiotic
prescribing indicators for measurement of antibiotic use and compliance
with policy and produces annual reports [9,10]. The C. difficile
infection HEAT target for 2009-11 has been reviewed by the Healthcare
Acquired Infection Task Force and a new C. difficile infection
target from April 2011 has been set using a `best in class' approach so
that by March 2013 the rate of C. difficile infection in patients
aged 65 and over is 0.39 cases or less per 1000 total occupied bed days in
all NHS boards. As a result of the impact of this work the University of
Dundee is being funded by Scottish Government's Healthcare Associated
Infection Task Force to work with National Services Scotland on the
development of further quality indicators of hospital antibiotic
prescribing. Internationally, the Clinical Excellence Commission in
Sydney, Australia invited Davey to be a consultant in February
2013, and has subsequently adapted the ESAC quality indicators for
implementation across New South Wales .
Sources to corroborate the impact
- Adriaenssens N and Coenen S, for European Surveillance of Antibiotic
Prescribing Management Team (2010) Disease-specific antibiotic
prescribing quality indicators report. http://ecdc.europa.eu/en/activities/surveillance/esac-net/publications/documents/report_disease_specific_antibiotic_prescribing_quality_indicators.pdf
- Corroboration statement from the Co-ordinator, European Surveillance
of Antibiotic Consumption, Belgium.
- Scottish Antimicrobial Prescribing Group (2011) Scottish Antimicrobial
Prescribing Group Progress Report for 2008-2011; available at http://www.scottishmedicines.org.uk/files/sapg/SAPG_Progress_Report_2008-11.pdf.
- Infectious Diseases Research Network. ORION Statement Website. http://www.idrn.org/orion.php.
- Corroboration statement from Project Lead, Scottish Antimicrobial
Prescribing Group, Scottish Medicines Consortium, Scottish Medicines
Hospital Care Subproject Group (2011) Identification of targets
for quality improvement in antimicrobial prescribing: the web-based ESAC
Point Prevalence Survey 2009. J. Antimicrob. Chemother. 66,
443-49 (DOI: 10.1093/jac/dkq430).
- Andrea Patton on behalf of Scottish Antimicrobial Prescribing Group
(2010) CDI HEAT Target (CEL April 2009) Hospital-based Empirical
Prescribing National Report May 2010. http://www.scottishmedicines.org.uk/files/SAPG_Antimicrobial_Supporting_Indicators_Report_Final_National_Report_May_2010.pdf
- McGuire M, Keel A and Scott B (Chief Nursing Officer Directorate)
(2009) A revised framework for national surveillance of Healthcare
Associated Infection and the introduction of a new Health Efficiency and
Access to Treatment (HEAT) target for Clostridium difficile-associated
disease (CDAD) for NHS Scotland. Scottish Government, Edinburgh. http://www.sehd.scot.nhs.uk/mels/CEL2009_11.pdf
- Scottish Antimicrobial Prescribing Group (2010) Scottish Antimicrobial
Prescribing Group Annual Report 2008-2009. http://www.scottishmedicines.org.uk/files/sapg/SAPG_AR_Lo-Res.pdf.
- Scottish Antimicrobial Prescribing Group (2012) Empirical Prescribing
Indicator Report April 2011 - December 2011
- Corroboration statement from Acting Deputy Chief Executive Officer,
Clinical Excellence Commission of New South Wales, Australia.