This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
A new toolkit, called the antibiotic review kit, was associated with more appropriate prescribing of antibiotics. Research linked implementation of the kit to a change in clinicians’ prescribing behaviour, and to a sustained reduction in antibiotic use.
People with severe illness or injury often need to be prescribed antibiotics when they are acutely unwell; it can be dangerous to delay treatment until laboratory tests have confirmed that the infection is bacterial. However, antibiotic treatment is often continued once a patient has recovered or when tests have ruled out a bacterial cause (meaning antibiotics are unnecessary).
Using antibiotics unnecessarily increases the chance of bacteria developing resistance, and rendering the antibiotics ineffective. Researchers developed the antibiotic review kit to prompt clinicians to stop unnecessary antibiotics. In this study, hospitals’ implementation of the kit was linked to sustained, reduced antibiotic use.
The antibiotic review toolkit was effective and safe, the study found. A year after it was implemented, hospitals had reduced their overall antibiotic use by almost 5% per year, compared with before. A slight increase in death rates (3%) was seen only after the pandemic hit in March 2020.
The team is now exploring how the toolkit can be used with the electronic prescribing systems used by most hospitals in England.
More information about antibiotic resistance is available on the NHS website.
The issue: unnecessary use of antibiotics in acute care
Antibiotics are used to treat or prevent some types of bacterial infection. They kill or prevent spread of bacteria. But overuse of antibiotics can mean that bacteria develop resistance; the antibiotics then become ineffective. Globally, antibiotic-resistant bacteria kill more than 1 million people each year, and unless practice changes, research suggests this figure will rise to 10 million people each year by 2050.
People on acute care wards in hospital are often given antibiotics before laboratory tests confirm that they have a bacterial infection. Prescribers therefore need to review antibiotic prescriptions and stop them when they are unnecessary. The Department of Health and Social Care (DHSC)’s Start smart – then focus guidance aims to reduce antibiotic use by requiring prescribers to review antibiotic prescriptions every 2 to 3 days.
In practice, prescribers find it difficult to decide to stop antibiotics, which have often been started by someone else. As a result, few reviews result in a decision to stop. Hospital antibiotic use continued to rise year on year until the COVID-19 pandemic in 2020. Prescribers do not have evidence-based tools to help them implement the DHSC Start smart – then focus guidelines and stop unnecessary antibiotics.
The antibiotic review kit recognises the uncertainty which often exists when antibiotics are started. An ‘initial’ time-limited prescription for ‘possible’ or ‘probable’ bacterial infection is reviewed within 72 hours. At that point, the prescriber’s approach is to ‘Stop unless I can justify continuing’; they write a ‘finalised’ prescription only if there is justification (confirmed bacterial infection, for example).
The kit has 4 elements:
• a prescribing decision aid which makes it easier for prescribers to stop antibiotics at a review within 72 hours
• online training, which takes approximately 15 minutes
• implementation guidance (to help acute care wards use the toolkit)
• a patient leaflet (explaining why they might be prescribed antibiotics and then be taken off them).
This study assessed the impact of the antibiotic review kit on antibiotic use in hospitals, and whether it affected rates of death.
What’s new?
Between February 2018 and July 2019, the toolkit was introduced into acute care wards at 39 UK hospitals. All provided data on clinical outcomes (including rates of death and length of stay); 38 provided data on antibiotic use.
The researchers collected data from the hospitals for the 2 years before the toolkit was introduced, and for at least 14 months afterwards. Doctors (who prescribe) were trained by the researchers on the toolkit, along with other key members of staff, such as nurses and pharmacists.
Different hospitals used different elements of the toolkit. The study found that:
- overall, less antibiotics were prescribed in hospitals after the toolkit was introduced than before; there was a sustained reduction in the total antibiotic use per patient (of 5% per year, on average)
- reductions were greater in hospitals which integrated the decision aid into the prescription process (paper charts or ePrescribing systems) and in which more staff had completed training
- use of the toolkit was safe; the slight increase in rates of death (by 3% per year) after the toolkit was introduced was only seen from March 2020 onwards and was likely to have been caused by the pandemic.
Why is this important?
The antibiotic review kit was linked to reduced antibiotic prescriptions and was safe. The researchers say the study shows it is possible to change antibiotic prescribing behaviour in hospitals over a long timeframe.
The toolkit focuses on decisions to stop antibiotics, a couple of days after they have been started. The researchers say this means that antibiotic prescribing could be reduced without withholding these drugs from people with acute illness.
At the start of the study, the researchers hoped to see a 15% reduction in overall antibiotic use. The 5% reduction found in this study is less than this, but still substantially more than the 1% required of acute NHS trusts at the time of the study. The researchers say that even a small reduction in antibiotic prescribing could help prevent antibiotic resistance.
Hospitals with higher rates of training on the toolkit had greater reductions in antibiotic prescribing in this study. This backs the suggestion that the strategies in the toolkit can lead to lasting behaviour change.
Clinicians who do not prescribe (some nurses, for instance) still guide prescribing decisions by letting prescribers know if a patient is feeling worse after an antibiotic has been stopped, for example. Pharmacists can also alert doctors when antibiotic prescriptions have not been reviewed, and when laboratory results are available.
The study could not demonstrate that the toolkit caused the reduction in prescribing antibiotics. Some hospitals could have improved their management of antibiotics after hearing of good practice elsewhere, for example. The study also did not assess the impact of the toolkit on antibiotic-associated harms, such as the development of antibiotic-resistant bacteria.
What’s next?
The researchers call for hospitals to use the toolkit in staff training, and embed it in their prescribing processes and stewardship work.
The toolkit was designed to fit in with standard practice at the time of the study. Most hospitals then used paper charts to monitor prescribing. Many of the hospitals in Wales and Northern Ireland (where paper-based systems are used) are still using the toolkit. But many hospitals in England now use online systems which do not work with the toolkit. The researchers have applied for funding to test how to use the toolkit with electronic prescribing methods.
You may be interested to read
The paper this Alert is based on: Antibiotic review kit for hospitals (ARK-Hospital): a stepped-wedge cluster-randomised controlled trial. Lancet Infectious Diseases 2023;23:207-221.
A study exploring the feasibility of using the toolkit: Adaptation and implementation of the ARK (Antibiotic Review Kit) intervention to safely and substantially reduce antibiotic use in hospitals: a feasibility study. Journal of Hospital Infection 2019;103:268-275.
A study about a hospital’s experience of starting to use the toolkit discussed in this Alert: Implementation of the Antimicrobial Review Kit (ARK) to optimise antimicrobial prescribing at the Royal Cornwall Hospital: a behavioural change odyssey. Clinical Medicine Journal 2022;22:455-460.
A blog discussing issues around stopping antibiotic overprescribing: It’s time to put a hard stop to antibiotic overprescribing in hospitals. BMJ Opinion 6 March 2019.
Funding: This study was funded by the NIHR Programme Grants for Applied Research.
Conflicts of Interest: The study authors declare no conflicts of interest.
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