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Measure  –  Appropriate use

Humans

It is important to understand if the right antibiotic at the right dosage and duration is being used for the right bacterial infection. This can be referred to as the quality or appropriateness of prescribing, dispensing or use.

What is appropriate use?

In the most simple form, appropriateness of antibiotic use is defined as adherence to treatment guidelines. More specifically, appropriateness in human medicine can be summarized in 5 “rights”:

  • Right patient
  • Right antibiotic
  • Right time
  • Right dose
  • Right duration

Measuring appropriateness of use is not always easy as it depends on several variables such as diagnostic capacity, training of staff and availability of antibiotics. Since the majority of inappropriate use is a matter of using antibiotics when they should not be used at all, antibiotic consumption is often used as a proxy for appropriate use.

Measure appropriateness of antibiotic use

Data on the appropriate use of antibiotics can help to monitor compliance with treatment protocols, provide targets for quality improvement or to plan rational use initiatives.

Evaluations on appropriateness of antibiotic use may address the following:

  • Why antibiotics are prescribed and for whom
  • Choice of antibiotics, dosage and treatment duration
  • Adherence to treatment guidelines
  • Whether patients take their antibiotics correctly

In health care settings, appropriateness of use can be defined as adherence to guidelines. Reviewing patient medical records and comparing prescriptions to clinical indications is a method to measure appropriateness of use. Point prevalence studies can be useful to get a snapshot of prescribing practices and explore potential opportunities for improving antibiotic use. Outside of health care settings, knowledge, attitude, beliefs and practices (KABP) surveys can be used to gather insight into how patients are consuming antibiotics at home.

The resources below have been divided into the following tables:

  • Tools and guidelines
  • Data and reports

See also related sections on Consumption and Knowledge and practices.

Selected Resources

Tools and guidelines

Resource Description
Global Point Prevalence Survey on Antimicrobial Consumption and Resistance Open PPS survey and protocols. This open to join initiative allows participating hospitals to monitor antimicrobial prescribing and resistance in hospital patients through a “one day survey” and helps design hospital interventions to promote prudent use. Hospitals are welcome to join survey and network (already more than 300 institutions from over 50 countries worldwide have participated). For documents such as protocols, data collection templates and presentations in different languages for personal use click here. A scientific article with results from the project has been published in the Lancet Global Health.
How to Investigate Antimicrobial Use in Hospitals: Selected Indicators Manual that defines indicators to help assess the management and use of antibiotics in hospitals and provides tools and step-by-step instructions for designing and carrying out assessment activities. Also available in French and Spanish.
How to Investigate Drug Use in Health Facilities: Selected Drug Use Indicators – EDM Research Series No. 007 Manual that defines a limited number of objective measures that can describe the drug use situation in a country, region or individual health facility.
How to investigate drug use by consumers Manual that provides a practical guide to the methods that can be used to investigate the use of medicines by consumers to identify problems, design interventions, and measure changes.
Quality Rand/UCLA appropriateness of use method Manual that presents step-by-step guidelines for conceptualising, designing, and carrying out a study of the appropriateness of medical or surgical procedures (for either diagnosis or treatment) using the RAND/UCLA Appropriateness Method.
Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals Journal article describing an intervention on appropriate antibiotic prescribing grounded in behavioral theory. A root cause analysis of inappropriate prescribing was performed, and then prescribers were offered a free choice of how to improve their antimicrobial prescribing based on this analysis. The Root Cause Analysis Interview Topic List can be found in supplemental content.
Antimicrobial Resistance, Antibiotic Usage, and Infection Control – A Self-Assessment Program for Indonesian Hospitals (PDF, 2MB) Method. Page 10 describes a method to measure the quality of antibiotic prescribing. Attachment 7  Form ‘Quality assessment of antibiotic use’ and Attachment 8 Flow chart ‘quality assessment antibiotic use’ can be adapted and used.
Survey protocol in nationwide hospital point-prevalence surveys in Sweden, 2003-2010 Data collection form for a point-prevalence survey performed nationwide in Sweden during 2003-2010. The results were published in Eurosurveillance.
Assessment tools for antibiotic use
Assessment tools from the CDC that can help facilities explore potential opportunities for improving antibiotic use overall in hospitals and for urinary tract infections, community-acquired pneumonia, resistant gram-positive infections, and for inpatients. At bottom of page.

Data and reports

Resources Description
Improving rational drug use in Africa: the example of Sudan Review on patterns of drug prescribing, dispensing and self-medication in Sudan. It identifies high rates of inappropriate prescribing, dispensing practices and prevalence of self-medication with antimicrobials despite implementation of interventions. Multifaceted interventions are recommended to address the irrational drug use.
Inappropriate antibiotic prescribing and demand for antibiotics in patients with Upper respiratory tract infections in primary care Journal article with a posthoc analysis of a cross-sectional study of patients with upper respiratory tract infections from Argentina, Denmark, Lithuania, Russia, Spain and Sweden (happy audit project). It found 45% of the prescribing cases to be unnecessary.
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU Report that describes results of the ARNA (‘Antimicrobial resistance and the causes of non-prudent use of antibiotics’) project, focusing on reasons for non-prescription use of antibiotics in the EU, and actions to prevent such use. Carried out under a contract with the European Commission.
Appropriateness of Antimicrobial Therapy Measured by Repeated Prevalence Surveys Journal article stating that inappropriate antimicrobial therapy was given to a substantial number of patients in a teaching hospital in the Netherlands.
Different Patterns of Inappropriate Antimicrobial Use in Surgical and Medical Units at a Tertiary Care Hospital in Switzerland: A Prevalence Survey Journal article with an audit of antimicrobial use at regular intervals among all patients hospitalized in predefined surgical, medical, haemato-oncological, or intensive care units. The audit found 37.0% of therapeutic and 16.6% of prophylactic prescriptions to be inappropriate.
Association of Adverse Events With Antibiotic Use in Hospitalized Patients Journal article describing adverse events related to antibiotic use. The authors conclude that adverse drug reactions are common during antibiotic therapy, and that many events can be avoided with better antibiotic use.

More from "Appropriate use"

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Paget J, Lescure D, Versporten A, Goossens H, Schellevis F, van Dijk L. ARNA Final Report: Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU [Internet]. 2017 [cited 2017 Nov 15]. Available from: https://www.nivel.nl/en/publicatie/antimicrobial-resitance-and-causes-non-prudent-use-antibiotics-human-medicine-eu
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Sikkens JJ, Agtmael MA van, Peters EJG, Lettinga KD, Kuip M van der, Vandenbroucke-Grauls CMJE, et al. Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals: The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) Participatory Intervention Study. JAMA Intern Med [Internet]. 2017 Aug 1 [cited 2017 Oct 26];177(8):1130–8. Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2623529
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Tamma PD, Avdic E, Li DX, Dzintars K, Cosgrove SE. Association of Adverse Events With Antibiotic Use in Hospitalized Patients. JAMA Intern Med. 2017 Jun 12;
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Skoog G, Struwe J, Cars O, Hanberger H, Odenholt I, Prag M, et al. Repeated nationwide point-prevalence surveys of antimicrobial use in Swedish hospitals: data for actions 2003–2010. Eurosurveillance [Internet]. 2016 Jun 23 [cited 2017 Apr 25];21(25). Available from: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=22509
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Systems for Improved Access to Pharmaceuticals and Services. How to Investigate Antimicrobial Use in Hospitals: Selected Indicators [Internet]. Management Sciences for Health; 2012 [cited 2014 Aug 25]. Available from: http://siapsprogram.org/publication/how-to-investigate-antimicrobial-use-in-hospitals-selected-indicators/
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Fitch K, Bernstein SJ, Aguilar MD, Burnand B, LaCalle JR, Lazaro P, et al. The RAND/UCLA Appropriateness Method User’s Manual [Internet]. Santa Monica, CA: Rand; 2001 [cited 2015 Apr 23]. 109 p. Available from: http://www.rand.org/pubs/monograph_reports/MR1269.html
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Cusini A, Rampini SK, Bansal V, Ledergerber B, Kuster SP, Ruef C, et al. Different Patterns of Inappropriate Antimicrobial Use in Surgical and Medical Units at a Tertiary Care Hospital in Switzerland: A Prevalence Survey. PLoS ONE [Internet]. 2010 Nov 16 [cited 2015 Apr 27];5(11):e14011. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2982822/
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