Bridging the evidence gap for implementing antibiotic stewardship in Norway: Interventions, process measures and patient outcomes related to antibiotic prescribing in hospitals

Background: Antimicrobial resistance is a major challenge for patient safety worldwide, as a growing number of infections become difficult to treat and the advances made in modern medicine are threatened. Overuse and misuse of antibiotics accelerates the development of resistance. Optimizing treatment for the patients of today, while conserving effective antibiotics for future patients is therefore of great importance. Antimicrobial stewardship is a strategy and coherent set of actions which promote responsible use of antibiotics. Objectives: The main aim of this project was to contribute to the knowledge needed to implement antibiotic stewardship in Norwegian hospitals through a) determining the impact of audit with feedback and academic detailing with local target setting on antibiotic prescribing practice b) understanding how patient outcomes are associated with adherence to clinical guidelins on initiation of antibiotic treatment and c) determining whether targets for antimicrobial stewardship interventions can be identified through analysing the antibiotic prescribing process in Norwegian hospitals with patient-level data. Materials and methods: All three substudies were part of a combined multicentre study, performed within the specialties of pulmonary medicine, infectious diseases and gastroenterology at three hospitals in Western Norway. Study 1 included 1802 patients and was a randomised, controlled intervention study, assessing the impact of academic detailing, audit with feedback and local target setting on adherence to antibiotic guidelines and changes in locally defined targets. Study 2 and 3 were observational cohort studies, including 1756 patients and 1235 patients, respectively. Results: In study 1 there was an absolute increase in adherence to guidelines of 6% across all intervention wards (p=0.04). When analysed per specialty, pulmonary intervention wards had a 14% absolute increase in adherence (p=0.003), while other intervention wards had no observed impact of interventions on adherence. Intervention wards receiving audit with feedback decreased the use of broad-spectrum antibiotics (level and trend). Local target setting at one of the pulmonary wards led to a 30% increase in targeted prescribing behaviour (p