Title : Improving compliance with local guidelines for antibiotic prescriptions using PDSA methodology
Antimicrobial resistance is a major threat to global health, and primarily occurs due to the overuse of broad-spectrum antibiotics. If not addressed, we are headed towards a post-antibiotic era. To address this issue, in 2015, the World Health Organisation developed a Global Action Plan1 to counter antimicrobial resistance.
A pilot baseline audit was conducted at the emergency department in Mater Dei Hospital, Malta demonstrated that co-amoxiclav, a broad-spectrum antibiotic, was widely prescribed for most infections and was not in line with local and international guidelines. Despite local and international guidelines stating that for CURB ≤1 community acquired pneumonias (CAPs), amoxicillin should be used as a first-line therapy, the broad-spectrum antibiotic co-amoxiclav was prescribed as the first-line therapy in approximately 60% of patients.
To address the issue of inappropriate antibiotic use, a quality improvement project was conducted and centered around the implementation of three PDSA2 (Plan Do Study Act) cycles.
The first PDSA intervention consisted of several posters strategically placed in areas of the emergency department. The posters indicated that S. pneumoniae was the most common causative organism of CAP and that less than 1% of S. pneumoniae isolates taken from this specific emergency department were resistant to amoxicillin. The efficacy of this intervention was somewhat limited; we found that 9% of antibiotic prescriptions for CAPs fell in line with our guidance by the end of this cycle. The second intervention involved a video presentation displayed to ED clinicians hosted by the trainee and the head of the infection control department. By the end of this second intervention, compliance with local guidelines increased to 18%. The third PDSA intervention, rather than focusing on education, targeted prescribing behaviour; it involved amending all ED treatment charts and briefly stating the appropriate antibiotic choice for CAPs. This behaviour-oriented intervention was directly integrated with antibiotic prescribing. As a result, by the end of the third cycle, we saw the largest cumulative improvement, with 33% of prescriptions in compliance with local guidance for CAPs.
In summary, we noted a significant improvement in compliance with local guidelines for antibiotic prescriptions in the emergency department following three PDSA cycles. Our findings conclude that prescribers best respond to behaviour-targeted interventions as opposed to education-related interventions in order to elicit a tangible improvement in antibiotic prescribing practices in line with local guidelines. Such measures can help reduce the use of broad-spectrum antibiotics and prevent the emergence of antimicrobial resistance.