Tailored interventions to improve antibiotic use for lower respiratory tract infections in hospitals: a cluster-randomized, controlled trial.

Abstract

BACKGROUND: Limited data exist on the most effective approach to increase the quality of antibiotic use for lower respiratory tract infections at hospitals. METHODS: One thousand nine hundred six patients with community-acquired pneumonia or an exacerbation of chronic obstructive pulmonary disease (acute exacerbation of chronic bronchitis) were included in a cluster-randomized, controlled trial at 6 medium-to-large Dutch hospitals. A multifaceted guideline-implementation strategy that was tailored to baseline performance and considered the barriers in the target group was used. Principal outcome measures were (1) guideline-adherent antibiotic prescription, (2) adaptation of dose and dose interval of antibiotics according to renal function, (3) switches in therapy, (4) streamlining of therapy, and (5) Gram staining and culture of sputum samples. Secondary process outcomes were applicable to community-acquired pneumonia (e.g., timely administration of antibiotics) or acute exacerbation of chronic bronchitis (e.g., not prescribing macrolides). RESULTS: The rate of guideline-adherent antibiotic prescription increased from 50.3% to 64.3% in the intervention hospitals (odds ratio [OR], 2.63; 95% confidence interval [CI], 1.57-4.42; P=.0008). The rate of adaptation of antibiotic dose according to renal function increased from 79.4% to 95.1% in the intervention hospitals (OR, 7.32; 95% CI, 2.09-25.7; P=.02). The switch from intravenous to oral therapy improved more in the control hospitals (from 53.3% to 71.9%) than in the intervention hospitals (from 74% to 83.6%). The change from broad-spectrum empirical therapy to pathogen-directed therapy improved by 5.7% in the intervention hospitals (P = not significant). Fewer sputum samples were obtained from both the intervention group (rate of sputum samples obtained decreased from 55.8% to 53.1%) and the control group (rate of sputum samples obtained decreased from 49.6% to 42.7%). Timely administration of antibiotics for community-acquired pneumonia increased significantly in the intervention group (from 55.2% to 62.9%; OR, 2.49; 95% CI, 1.11-5.57; P=.026). CONCLUSIONS: With regard to some important aspects, tailoring interventions to change antibiotic use improved the quality of treatment for patients hospitalized with lower respiratory tract infection.