Hospitals will test a simple paper booklet and online training module designed to help doctors stop or shorten antibiotic prescriptions 24 to 72 hours after a patient is admitted. The problem is that broad-spectrum antibiotics are overused in acute medical wards. Official guidance recommends reviewing and revising these prescriptions after a day or two, but in practice few changes are made. Doctors fear that stopping antibiotics early in patients who genuinely had bacterial infections could increase mortality. Yet there is little evidence on how to safely implement such reviews, and no qualitative research has examined how patients and staff actually think about antibiotic duration in hospitals. If the intervention works, it could cut total antibiotic use in acute medical inpatients by at least 15 percent without raising death rates. The trial will run across 36 NHS Trusts, with each hospital acting as its own control over 18 months of staggered implementation, followed by 12 months of follow-up. Success would give the NHS a cheap, scalable tool to slow antimicrobial resistance while maintaining patient safety.
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Aims/objectives: To develop feasible, inexpensive interventions to increase prescriber compliance with antibiotic review&revise strategies in acute/general medical inpatients, and patient acceptability of shorter antibiotic therapy durations driven by them To evaluate their safety and cost-effectiveness Background/rationale: Broad-spectrum antibiotics are commonly prescribed for acute/general medical inpatients, because delays in administering effective antibiotics increase mortality risk in those with bacterial infections, and what is wrong with a patient is frequently unclear at admission. Department of Health guidance on antimicrobial stewardship ( Start Smart then Focus ) recommends active review&revision of antibiotics 24-72 hours after initiation, but in practice relatively few prescription changes are made. This is perhaps not surprising given the lack of evidence to inform how review&revise should be implemented. Research plan: The goal of reducing total antibiotic burden in acute/general medical inpatients by at least 15% will be addressed through 6 work-packages. WP1-WP3 will provide underpinning data for design and piloting in WP4 of a review&revise intervention package for inpatients/carers and healthcare professionals WP5 will evaluate its effectiveness and safety WP6 will conduct health-economic evaluations. WP1 is an overview to summarise the systematic review evidence for the effectiveness and safety of short- versus longer antibiotic courses in hospitalised patients across indications, to address concerns that stopping antibiotics early in those who have genuinely had bacterial infections could lead to poorer individual-level outcomes. The overview will draw on methods and search terms used by co-applicants for previous systematic reviews/overviews in Primary Care antibiotic prescribing. WP2 contains two observational analyses investigating antibiotic usage and outcomes in inpatients admitted to acute/general medicine at hospital and speciality level, using Hospital Episode Statistics and data from the University Hospitals Birmingham NHS Trust. Completely adjusting for confounding in such analyses is difficult; the goal is to assess whether there is strong evidence of harm (greater rates of treatment failure/mortality associated with less antibiotic use), when confounding would have lesser impact. WP3 consists of qualitative studies with healthcare professionals and patients/carers to deepen understanding of perceptions and experiences of inpatient antibiotic prescribing (particularly focussing on antibiotic duration, not addressed in qualitative research in hospitals to date), and to identify barriers to change to be addressed in WP4. WP4 will develop a feasible, generalisable and sustainable multi-component healthcare professional and inpatient/carer intervention to support antibiotic review&revise , informed by relevant theory, existing evidence, and WP1-WP3 findings. This will be piloted and evaluated using mixed methods. We envisage the patient/carer intervention will be a simple, generic paper booklet and the patient/healthcare professional intervention will include a personalised internet-based educational module for self-completion and standardised review&revise management/review algorithm and proforma, supported by regular antibiotic stewardship ward rounds/review. WP5 will evaluate this intervention in acute/general medical admissions in 36 NHS Trusts using a hospital-randomised stepped-wedge cluster RCT, where each hospital acts as its own control. The intervention will be implemented in two Trusts per month over 18 months. A further 12 months follow-up in all hospitals will assess sustainability of any intervention effect. Co-primary outcomes will be 30-day mortality post-admission (non-inferiority) and defined-daily-doses of antibiotics per acute/general medical admission (superiority). The intervention will be considered suc
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