Measuring Appropriate Antibiotic Prescribing in Acute Hospitals: Development of a National Audit Tool Through a Delphi Consensus
2.1. Defining Appropriateness
- Prescribing an antibiotic for a patient in the absence of (documented) evidence of bacterial infection.
- Prescribing a critical broad-spectrum antibiotic to patients in the absence of a (documented) rationale.
- Continuing an antibiotic prescription beyond the course length recommended in local or national guidelines, in the absence of a (documented) rationale.
2.2. Initial Draft of Audit Tool
2.3. Round 1 Delphi
2.4. Round 2 Delphi
3.1. Study Strengths and Limitations
3.2. Future Work
4. Materials and Methods
4.1. Part 1: Development of the Audit Tool
4.2. Part 2: Validation of the Audit Tool
- Initiation (was the antibiotic indicated and necessary at the start date?);
- Early post prescription review (was the antibiotic continued after infection was ruled out?);
- End of therapy (was the antibiotic continued beyond the standard duration?).
Conflicts of Interest
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|Prescribing Elements (Potential Audit Variables)||Comments||Selected for Audit|
|No antibiotic if not indicated (no reasonable evidence of infection)||Unnecessary antibiotic exposure selects for avoidable resistance [9,10,11].||✓|
|Indication documented||Good practice for continuity of care but of uncertain relevance to resistance.||✓|
|Appropriate specimens taken for microscopy, culture, and sensitivity (MC&S)—blood cultures and suspected site of infection||Important for establishing evidence of infection and for targeting appropriate therapy but requires manual audit and >50% of cultures are negative [12,13].||✓|
|No allergy or contra-indication to treatments||Important patient safety consideration but not relevant for resistance.||✕|
|Prompt administration of first dose||Important patient safety consideration in cases of severe sepsis but of uncertain relevance to resistance. Already captured by national sepsis audits.||✕|
|Treatment regimen adequate to cover most likely pathogens||Meta-analysis of RCTs reports increased risk of mortality if initial regimen inadequate . Relevance to resistance uncertain.||✓ *|
|Treatment regimen not unnecessarily broad spectrum||Indiscriminate use of critical broad-spectrum agents unnecessarily selects for resistance [15,16,17].||✓ *|
|No redundant agents in treatment regimen||Unnecessary antibiotic exposure selects for avoidable resistance [9,10,11].||✓|
|Treatment regimen compliant with local/national guideline or justified deviation||Validity dependent upon quality of local guideline. Relevance to resistance uncertain.||✕|
|Treatment regimen cost-effective||Not relevant to resistance.||✕|
|No underdosing||Limited evidence from modeling suggests that low doses may select resistance in pneumococci  but underdosing unlikely to be a problem in NHS hospitals due to pharmacist and nurse intervention.||✕|
|No overdosing||Important patient safety consideration but likely to reduce rather than increase risk of selecting resistance [19,20,21,22,23,24].||✕|
|Correct route of administration||Relevant for efficacy, length of stay, and risk of line infection but of uncertain relevance to resistance.||✕|
|Prompt appropriate source control||Subjective assessment. Of uncertain relevance to resistance.||✕|
|No missed doses or delayed doses||Of uncertain relevance to selection of resistance.||✕|
|Therapeutic drug monitoring (TDM) for narrow therapeutic index drugs||Important primarily for patient safety (but also for efficacy); of uncertain relevance to resistance.||✕|
|Prompt discontinuation of antibiotics if alternative diagnosis established and infection excluded||There is RCT evidence that unnecessary continuation selects for multi-resistant organisms [25,26,27].||✓|
|Appropriate broadening of spectrum in response to MC&S results||This may necessitate an increase in broad-spectrum agent use if indicated by MC&S results. Failure to adjust ineffective treatment to MC&S results is associated with a higher risk of mortality .||✓ *|
|Appropriate narrowing of spectrum in response to MC&S results||Evidence largely from observational studies suggests that de-escalation to narrow-spectrum agents is safe when patients are improving clinically and a plausible pathogen has been identified .||✓ *|
|Prompt referral to outpatient parenteral antibiotic therapy OPAT services for suitable patients||Relevant for length of stay and risk of healthcare-associated infection (HCAI) but of uncertain relevance to resistance.||✕|
|Prompt switch from IV to oral route of administration when safe and effective||Relevant for length of stay and risk of line infection but of uncertain relevance to resistance.||✕|
|Antibiotic plan documented in the notes||Good practice for continuity of care but of uncertain relevance to resistance.||✕|
|No unjustified prolonged duration of treatment||There is evidence from RCTs and observational studies that unnecessarily prolonged duration selects for multi-resistant organisms [25,26,29]. Can only be audited at the end of therapy.||✓|
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Hood, G.; Hand, K.S.; Cramp, E.; Howard, P.; Hopkins, S.; Ashiru-Oredope, D., on behalf of Antibiotic Prescribing Appropriateness Measures (APAM) subgroup of the national Advisory Committee on Antimicrobial Resistance, Prescribing and Healthcare Associated Infection (ARPHAI). Measuring Appropriate Antibiotic Prescribing in Acute Hospitals: Development of a National Audit Tool Through a Delphi Consensus. Antibiotics 2019, 8, 49. https://doi.org/10.3390/antibiotics8020049
Hood G, Hand KS, Cramp E, Howard P, Hopkins S, Ashiru-Oredope D on behalf of Antibiotic Prescribing Appropriateness Measures (APAM) subgroup of the national Advisory Committee on Antimicrobial Resistance, Prescribing and Healthcare Associated Infection (ARPHAI). Measuring Appropriate Antibiotic Prescribing in Acute Hospitals: Development of a National Audit Tool Through a Delphi Consensus. Antibiotics. 2019; 8(2):49. https://doi.org/10.3390/antibiotics8020049Chicago/Turabian Style
Hood, Graeme, Kieran S. Hand, Emma Cramp, Philip Howard, Susan Hopkins, and Diane Ashiru-Oredope on behalf of Antibiotic Prescribing Appropriateness Measures (APAM) subgroup of the national Advisory Committee on Antimicrobial Resistance, Prescribing and Healthcare Associated Infection (ARPHAI). 2019. "Measuring Appropriate Antibiotic Prescribing in Acute Hospitals: Development of a National Audit Tool Through a Delphi Consensus" Antibiotics 8, no. 2: 49. https://doi.org/10.3390/antibiotics8020049