Table 2. Outcomes of interventions to improve appropriate prescribing and use of antibiotics in hospitals in low-and middle-income countries: controlled trials.
| Intervention type and study design | Study duration, weeks | No. of patients | Data summary | Outcome measure | Effect size | P |
|---|---|---|---|---|---|---|
| Structural intervention | ||||||
| Procalcitonin guidance | ||||||
| Randomized controlled trial18 | 201 | 172 | No. of patients receiving antibiotics: 72/86 in procalcitonin group; 79/86 in routine care group | RR of receiving antibiotic (95% CI) | 0.87 (0.79 to 0.96) | 0.01 |
| Randomized controlled trial20 | NR | 205 | No. of patients receiving antibiotics: 19/102 in procalcitonin group; 48/103 in routine care group | RR of receiving antibiotic (95% CI) | 0.40 (0.25 to 0.63) | 0.01 |
| No. of deaths: 3/102 in procalcitonin group; 3/103 in routine care group | RR of in-hospital death (95% CI) | 0.88 (0.33 to 2.35) | 0.80 | |||
| Randomized controlled trial17 | 154 | 78 | No. of patients receiving antibiotics: 26/39 in procalcitonin group; 35/39 in routine care group | RR of receiving antibiotic (95% CI) | 0.74 (0.58 to 0.95) | 0.01 |
| No. of deaths: 21/39 in procalcitonin group; 20/39 in routine care group | RR of death after 30 daysa (95% CI) | 1.11 (0.76 to 1.64) | 0.42 | |||
| Randomized controlled trial24 | 133 | 71 | No. of deaths: 7/35 in procalcitonin group; 8/36 in standard 14 days of antibiotics group | RR of in-hospital death (95% CI) | 0.90 (0.37 to 2.22) | 0.99 |
| Randomized controlled trial23 | 141 | 97 | No. of deaths: 21/50 in procalcitonin group; 21/47 in routine care group | RR of in-hospital death (95% CI) | 0.92 (0.59 to 1.44) | 0.84 |
| Randomized controlled trial21 | 283 | 265 | No. of patients receiving antibiotics: 59/132 in procalcitonin group; 95/133 in routine care group | RR of receiving antibiotic (95% CI) | 0.63 (0.50 to 0.78) | 0.01 |
| Randomized controlled trial19 | 133 | 180 | No. of patients receiving antibiotics: 44/90 in procalcitonin group; 79/90 in routine care group | RR of receiving antibiotic (95% CI) | 0.56 (0.44 to 0.70) | 0.01 |
| Randomized controlled trial22 | 52 | 60 | No. of deaths: 5/30 in procalcitonin group; 4/30 in routine care group | RR of in-hospital death (95% CI) | 1.25 (0.37 to 4.21) | 0.71 |
| Rapid diagnostic testing | ||||||
| Non-randomized controlled trial26 | 21 | 97 | No. of patients receiving antibiotics: 34/50 in influenza rapid diagnostic test group; 47/47 in routine care group | RR of receiving antibiotic (95% CI) | 0.68 (0.56 to 0.82) | 0.01 |
| Randomized controlled trial25 | 26 | 201 | No. of patients receiving antibiotics: 29/100 in faecal leukocyte + rotavirus rapid test group; 50/101 in faecal leukocyte test only group | RR of receiving antibiotic (95% CI) | 0.59 (0.41 to 0.84) | 0.03 |
| Library access plus workshops | ||||||
| Cluster randomized controlled trial27 | 43 to 52b | 1000 to 1022 per hospital | Mean % of operations with antibiotic prophylaxis: Mexico: 25.8 in intervention group; 6.5 in control group Thailand: 26.0 in intervention group; 14.7 in control group |
% of operations with antibiotic prophylaxis: difference in adjusted rate (95% CI) | Mexico: 19 (−8 to 46) | 0.12 |
| Thailand: 5 (−18 to 27) | 0.66 | |||||
| Persuasive intervention | ||||||
| Audit and feedback on individual patient cases | ||||||
| Non-randomized controlled trial32 | 17 | 948 | Mean no. of days of hospitalization: 30.4 in intervention group; 30.7 in control group | Mean difference in hospital length of stay (95% CI), days | −0.3 (−3.3 to −3.0) | 0.80 |
| Mean no. of days of treatment: 12.7 in intervention group; 16.4 in control group | Mean difference in treatment duration, days | −3.7 (−5.2 to −2.2) | 0.01 | |||
| Cluster randomized controlled tria33 | 43 | 436 | Mean no. of days of hospitalization: 14.2 in intervention group; 15.8 in control group | Mean difference in hospital length of stay (95% CI), days | −1.6 (−2.9 to −0.3) | 0.03 |
| Non-randomized controlled trial30 | 9 | 874 | Median no. of days of treatment: 4.0 in intervention group; 5.0 in control group | Difference in median no. of days of treatment | 1.0 | 0.03 |
| Intervention bundle | ||||||
| Treatment guidelines plus education plus audit and feedback | ||||||
| Cluster randomized controlled trial37 | 77 | 1160 | No. of patients receiving antibiotics for inappropriate indication: 313/594 in intervention group; 437/566 in control group | Absolute risk reduction for receiving antibiotic for inappropriate indication (95% CI) | 41 (−6 to 88) | 0.08 |
CI: confidence interval; DDD: defined daily doses; NR: not reported; RR: relative risk.
a Per protocol analysis.
b Different collection periods in different hospitals.
Note: Intention-to-treat analysis results are reported unless indicated otherwise. When significant P-values were not specified, we assumed P < 0.05 as significant.