A Cochrane review [Abstract] 1 included 221 studies (58 RCTs, and 163 non-randomised studies, NRS). The studies tested interventions that fell broadly into two categories: restrictive techniques, which apply rules to make physicians prescribe properly, and enablement techniques, which provide advice or feedback to help physicians prescribe properly.
More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% CI 14% to 16%; n=23 394). This represents an increase from 43% to 58%.The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67 days; 14 RCTs, n=3 318) from 11.0 days. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs, n=15 827). Antibiotic stewardship interventions reduced length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs, n=3 834). One RCT and 6 NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams.
Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions. Enabling interventions that included feedback were probably more effective than those that did not.
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