A simple intervention to improve hospital antibiotic prescribing

To the Editor: Australia has a high rate of antibiotic use. Increasing antibiotic resistance, spiralling pharmaceutical cost, need for evidence-based practice, public awareness, and widespread variation in prescribing practice, which may lead to quality and safety issues, are reported as the drivers for improving antibiotic use and prescribing.

South et al are to be commended for the introduction of a laminated card for doctors as a simple intervention to improve prescribing practices.1 Despite the passive nature of the intervention, they found significant improvement in the appropriateness of prescribing.

The authors acknowledge that they are not claiming that their intervention “is the cause or only cause” for change in practice. Areas like antibiotic prescribing and physician behaviour are highly complex and require a series of systematic approaches. Doctors are only one of the multiple stakeholders involved in this process. The level of experience, training background, and awareness of the public health and clinical implications of such interventions vary widely among doctors.

Improvement of South et al’s methodology from a passive mailout to gathering systematic baseline information about the medical staff involved, clarifying the purpose of the initiative and finding the proportions of uptake among junior and senior staff would have made the intervention more robust. One of the fundamentals of any change process is to instil a sense of urgency and develop a coalition to drive and lead it.

Development and evaluation of quality initiatives need more than just passive information provision. It has been suggested that any such quality and safety initiative should have set priorities, and these priorities should be developed using a systematic evaluation process with explicit criteria.2 Various systemic strategies that involved systematic methodology and evaluation processes, such as antibiotic decision support systems (both computer and manual) and drug utilisation reviews, reported sustainable changes in prescribing practices.3

The intervention by South et al is a welcome initiative, but it is important to realise that simplifying a complex problem like drug prescribing may lead to setting up wrong priorities for action and trivialise the problem and solution. Such initiatives will suffer the fate of the many quality programs that we hear about in hospital corridors but which fail to make a sustainable change.