Table 3. Outcomes of interventions to improve appropriate prescribing and use of antibiotics in hospitals in low-and middle-income countries: interrupted time-series studies.
| Intervention | Study segments (duration in weeks) | No. of data points per segment (no. of observations per data point) | Outcome measure | Effect sizea | P |
|---|---|---|---|---|---|
| Structural interventions | |||||
| Mobile phone application28 | S1: Pre-intervention (52) | 12 (NR) | DDD per 1000 bed-days | Baseline trend NR | N/A |
| S2: Post-intervention (52) | 12 (NR) | Trend increased for amikacinb | 0.02 | ||
| Trend increased for cefepimeb | 0.01 | ||||
| Trend decreased for piperacillinb | 0.02 | ||||
| Trend decreased for meropenemb | 0.44 | ||||
| Trend decreased for polymyxinb | 0.34 | ||||
| Trend decreased for ciprofloxacinb | 0.08 | ||||
| Persuasive interventions | |||||
| Audit and feedback on individual patient cases29 | S1: Pre-intervention (70) | 16 (NR) | DDD per 100 bed-days | Baseline level NR | N/A |
| Baseline trend +0.064/month | 0.62 | ||||
| S2: Implementation (104) | 24 (NR) | Level change NR | N/A | ||
| Trend change −0.56/month | 0.01 | ||||
| S3: Post-intervention (86) | 20 (NR) | Level change NR | N/A | ||
| Trend change −0.20/month | 0.05 | ||||
| Audit and feedback at department level31 | S1: Pre-intervention (52) | 12 (NR) | DDD per 100 bed-days | Baseline level: NR | N/A |
| Baseline trend: increasing in 1/35 wardsb | 0.05 | ||||
| S2: Post-intervention (13) | 3 (NR) | Level decreased in 3/35 wardsb | 0.05 | ||
| Enabling interventions | |||||
| Treatment guidelines34 | S1: Pre-intervention (16) | 9 (14) | DDD per 100 bed-days | Baseline level: NR | N/A |
| Baseline trend: −1.0 per 14 days | 0.53 | ||||
| S2: Guideline development (14) | 6 (14) | Level change: −31.9 | 0.03 | ||
| Trend change +2.1 per 14 days | 0.52 | ||||
| S3: Guideline declaration (8) | 4 (26) | Level change: −29.2 | 0.11 | ||
| Trend change: −9.5 per 14 days | 0.14 | ||||
| S4: Teaching sessions (8) | 4 (27) | Level change: +38.2 | 0.05 | ||
| Trend change: +10.0 per 14 days | 0.21 | ||||
| S5: Refresher course (8) | 5 (15) | Level change: −2.4 | 0.88 | ||
| Trend change: −9.8 per 14 days | 0.15 | ||||
| Treatment guidelines35 | S1: Pre-intervention (86) | 20 (NR) | DDD per 100 bed-days | Baseline level: 56.9 | N/A |
| Baseline trend: +0.95 per month | 0.01 | ||||
| S2: Guideline preparation and booklet dissemination (94) | 22 (NR) | Level change: NR | N/A | ||
| Trend change: +0.21 per month | 0.03 | ||||
| S3: No new intervention (104) | 24 (NR) | Level change: NR | N/A | ||
| Trend change: +0.31 per month | 0.01 | ||||
| S4: Guideline revision and booklet dissemination (104) | 24 (NR) | Level change: NR | N/A | ||
| Trend change: +0.05 per month | 0.64 | ||||
| S5: Guideline revision and booklet with electronic dissemination (86) | 20 (NR) | Level change: NR | N/A | ||
| Trend change: −0.37 per month | 0.01 | ||||
| Intervention bundles | |||||
| Treatment guidelines plus structural changes39 | Hospital A | ||||
| S1: Pre-intervention (13) | 3 (308) | % of operations with surgical site infection | Baseline level: 13.9 | N/A | |
| Baseline trend: NRc | NR | ||||
| S2: Guideline introduction with structural changes (30) | 7 (272) | Level change: −9.8 | 0.01 | ||
| Trend change: NRc | NR | ||||
| S3: Post-intervention (21) | 5 (217) | Level change: NRc | NR | ||
| Trend change: NRc | NR | ||||
| Hospital A | |||||
| S1: Pre-intervention (13) | 3 (308) | % of caesarean sections with administration of antibiotic prophylaxis | Baseline level: 47.5 | N/A | |
| Baseline trend: NRc | NR | ||||
| S2: Guideline introduction with structural changes (30) | 7 (272) | Level change: +31.6 | 0.01 | ||
| Trend change: NRc | NR | ||||
| S3: Post-intervention (21) | 5 (217) | Level change: −4.9 | 0.01 | ||
| Trend change: NRc | NR | ||||
| Hospital B: | |||||
| S1: Pre-intervention (13) | 3 (396) | % of caesarean sections with administration of antibiotic prophylaxis | Baseline level: 5.1 | N/A | |
| Baseline trend: NRc | NR | ||||
| S2: Guideline introduction with structural changes (39) | 9 (1026) | Level change: NRc | NR | ||
| Trend change: +5.4 per month | 0.01 | ||||
| S3: Post-intervention (52) | 12 (709) | Level change: +7.1 | 0.05 | ||
| Trend change: −4.1 | 0.01 | ||||
| Hospital A | |||||
| S1: Pre-intervention (13) | 3 (308) | % of caesarean sections with administration of antibiotic prophylaxis within 1 hour of delivery | Baseline level: 32.5 | N/A | |
| Baseline trend: NRc | NR | ||||
| S2: Guideline introduction with structural changes (30) | 7 (272) | Level change: 62.2 | 0.01 | ||
| Trend change: NRc | 0.01 | ||||
| S3: Post-intervention (21) | 5 (217) | Level change: NRc | NR | ||
| Trend change: NRc | NR | ||||
| Hospital B | |||||
| S1: Pre-intervention (13) | 3 (396) | % of caesarean sections with administration of antibiotic prophylaxis within 1 hour of delivery | Baseline level: 30.8 | N/A | |
| Baseline trend: +18.4 per month | 0.01 | ||||
| S2: Guideline introduction with structural changes (39) | 9 (1026) | Level change: NRc | NR | ||
| Trend change: −18.7 per month | 0.01 | ||||
| S3: Post-intervention (52) | 12 (709) | Level change: +15.2 | NR | ||
| Trend change: NRc | NR | ||||
| Prescription form plus education plus reminders40 | S1: Pre-intervention (103) | 103 (NR) | % of operations with incorrect timing of antibiotic prophylaxis | Baseline level: NR | N/A |
| Baseline trend: NR | N/A | ||||
| S2: Post-intervention (42) | 42 (NR) | Level change: −20 | 0.01 | ||
| Trend change: NR | NR | ||||
| Antibiotic restrictions plus audit and feedback41 | S1: Pre-intervention (129) | 30 (NR) | Antibiotic use, DDD per 100 bed-days | Baseline level: NR | N/A |
| Baseline trend +1.2 per month | 0.01 | ||||
| S2: Antibiotic restrictions plus audit and feedback by infectious diseases specialist (94) | 22 (NR) | Level change: −1.3 | 0.8 | ||
| Trend change: −2.7 per month | 0.01 | ||||
| S3: Antibiotic restrictions plus audit and feedback by pharmacist (86) | 20 (NR) | Level change: +4.7 | 0.4 | ||
| Trend change: +1.2 per month | 0.01 | ||||
| Treatment guidelines plus education plus audit and feedback36 | Timing study | ||||
| S1: Pre-intervention (26) | 26 (NR) | % of operations with incorrect timing of antibiotic prophylaxis | Baseline level: 99% | N/A | |
| Baseline trend: NR | N/A | ||||
| S2: Post-intervention (40) | 40 (NR) | Level decreasedb | 0.01 | ||
| Trend decreasedb | 0.01 | ||||
| Infection study | |||||
| S1: Pre-intervention (26) | 6 (223) | % of operations with surgical site infection | Baseline level: NR | N/A | |
| Baseline trend: −0.5 per month | 0.49 | ||||
| S2: Post-intervention (39) | 9 (223) | Level change: NR | 0.05 | ||
| Trend change: −0.7 per month | 0.03 | ||||
| Multifaceted antibiotic stewardship programme42 | Outcome A | ||||
| S1: Pre-intervention (52) | 12 (NR) | % of patients receiving antibiotic | Baseline level: NR | N/A | |
| Baseline trend +0.3 per month | > 0.05 | ||||
| S2: Implementation (52) | 12 (NR) | Level change: −2.3 | > 0.05 | ||
| Trend change: −2.3 per month | 0.01 | ||||
| S3: Post-intervention (104) | 24 (NR) | Level change: −2.7 | 0.05 | ||
| Trend change: +1.9 per month | 0.01 | ||||
| Outcome B | |||||
| S1: Pre-intervention (52) | 12 (NR) | Antibiotic use, DDD per 100 bed-days | Baseline level: NR | N/A | |
| Baseline trend: −0.4 per month | 0.2 | ||||
| S2: Implementation (52) | 12 (NR) | Level change: +2.8 | > 0.05 | ||
| Trend change: −2.2 per month | 0.01 | ||||
| S3: Post-intervention (104) | 24 (NR) | Level change: −7.1 | 0.01 | ||
| Trend change: +2.4 per month | 0.01 | ||||
| Multifaceted antibiotic stewardship programme43 | S1: Pre-intervention (334) | 26 (58) | % of patients receiving antibiotic | Baseline level: 74.7 | N/A |
| Baseline trend: −0.3 per quarter | 0.01 | ||||
| S2: Post-intervention (78) | 6 (750) | Level change: −7.3 | 0.04 | ||
| Trend change: −1.5 per quarter | 0.07 | ||||
| Treatment guidelines plus antibiotic restrictions plus audit and feedback38 | S1: Pre-intervention (17) | 4 (375 985) | % of patients receiving antibiotic | Baseline level: 59.0 | N/A |
| Baseline trend: −3.0 per month | 0.01 | ||||
| S2: Guidelines and restrictions (21) | 5 (424 702) | Level change: +3.0 | 0.2 | ||
| Trend change: −0.4 per month | 0.6 | ||||
| S3: Financially punished audit and feedback (60) | 14 (446 727) | Level change: −9.0 | 0.01 | ||
| Trend change: +3.0 per month | 0.01 |
DDD: defined daily doses; N/A: not applicable; NR: not reported; RR: relative risk; S: segment.
a In interrupted times-series studies the linear curve which summarizes the outcome data in each study segment can be defined by its level (y-intercept) and trend (slope). Level change reflects the difference of the level of the current segment compared with the level of the previous segment. Trend change reflects the difference of the trend of the current segment compared to the trend of the previous segment.
b The authors reported no values for level or trend changes.
c The authors reported that there were no significant changes but with no values for levels or trend changes.