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Limited effect of patient and disease characteristics on compliance with hospital antimicrobial guidelines

  • Pharmacoepidemiology and Prescription
  • Published:
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Abstract

Objective

Physicians frequently deviate from guidelines that promote prudent use of antimicrobials. We explored to what extent patient and disease characteristics were associated with compliance with guideline recommendations for three common infections.

Methods

In a 1-year prospective observational study, 1,125 antimicrobial prescriptions were analysed for compliance with university hospital guidelines.

Results

Compliance varied significantly between and within the groups of infections studied. Compliance was much higher for lower respiratory tract infections (LRTIs; 79%) than for sepsis (53%) and urinary tract infections (UTIs; 40%). Only predisposing illnesses and active malignancies were associated with more compliant prescribing, whereas alcohol/ intravenous drug abuse and serum creatinine levels >130 μmol/l were associated with less compliant prescribing. Availability of culture results had no impact on compliance with guidelines for sepsis but was associated with more compliance in UTIs and less in LRTIs. Narrowing initial broad-spectrum antimicrobial therapy to cultured pathogens was seldom practised. Most noncompliant prescribing concerned a too broad spectrum of activity when compared with guideline-recommended therapy.

Conclusion

Patient characteristics had only a limited impact on compliant prescribing for a variety of reasons. Physicians seemed to practise defensive prescribing behaviour, favouring treatment success in current patients over loss of effectiveness due to resistance in future patients.

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Acknowledgements

The authors thank the hospital board and the Dutch Health Insurance Board for the unconditional grant that made this study possible. We thank the doctors of the department of internal medicine for access to the medical dossiers. We thank D. Zhang and I. Oord for their unrelenting collection of data.

Author information

Authors and Affiliations

  1. Department of Clinical Pharmacology, University Medical Centre Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, Netherlands

    Peter G. M. Mol, Petra Denig, Prashant V. NannanPanday & Flora M. Haaijer-Ruskamp

  2. Hospital and Clinical Pharmacy Department, University Medical Center Groningen, Groningen, Netherlands

    Peter G. M. Mol, Prashant V. NannanPanday & Marian Laseur

  3. Department of Clinical Microbiology, University Medical Center Groningen, Groningen, Netherlands

    John E. Degener

  4. Department of Internal Medicine, University Medical Center Groningen, Groningen, Netherlands

    Rijk O. B. Gans

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  1. Peter G. M. Mol
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  2. Petra Denig
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  7. Flora M. Haaijer-Ruskamp
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Corresponding author

Correspondence to Peter G. M. Mol.

Appendix

Appendix

Hospital guidelines, University Medical Center Groningen [19]

The guideline consists of 17 chapters on antimicrobial therapy and eight chapters on antimicrobial prophylaxis. Additional chapters give recommendations on antimicrobial use for pregnant and breastfeeding women and for renal- and hepatic-impaired patients, and antibacterial sensitivity patterns of isolated pathogens in the hospital. The guideline also gives general recommendations on when and how to take appropriate bacterial culture samples and how to streamline therapy. Literature references are given, on which the guideline recommendations are based. As an example for the three most common type of infections, guideline-recommended agents for empiric therapy are given below. The guideline also gives recommendations on dosing, administration route, and duration of therapy (not shown).

Type of infection

Recommended drug choice

Urinary tract infection (UTI)

 

Lower UTI

 

-Uncomplicated

Nitrofurantoin, trimethoprim (or norfloxacin)

-Male

Co-trimoxazole

-Catheter in situ (with fever)

Amoxicillin + tobramycin

Acute pyelonephritis

Cefuroxime + tobramycin, or ciprofloxacin

Sepsis

-Urosepsis, no catheter

Cefuroxime or tobramycin

-Urosepsis, catheter in situ

Amoxicillin + (ciprofloxacin or tobramycin)

-Hospital-acquired pneumonia

Cefuroxime + tobramycin

-Abdominal, unknown location

Amoxicillin + tobramycin+metronidazole

-Abdominal, bile duct

Piperacillin + tobramycin

Lower respiratory tract infections

Community-acquired pneumonia (suspected Legionella)

Co-amoxiclav (+ erythromycin)

Hospital-acquired pneumonia, severe or with additional risk factors

Cefuroxime + tobramycin, or ceftazidime

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Mol, P.G.M., Denig, P., Gans, R.O.B. et al. Limited effect of patient and disease characteristics on compliance with hospital antimicrobial guidelines. Eur J Clin Pharmacol 62, 297–305 (2006). https://doi.org/10.1007/s00228-005-0058-y

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