Why using less antibiotics in hospitals is a challenge

Disease and treatment 8. jan 2021 3 min Professor Thomas Benfield Written by Kristian Sjøgren

Hospitals would prefer to be certain that an infection is eradicated rather than follow Denmark’s guidelines on antibiotic use. A researcher says that this makes reducing antibiotic resistance more difficult.

Denmark’s official guidelines recommend 5–7 days of antibiotic treatment for people with community-acquired pneumonia depending on the severity. This is enough to bring the infection under control and yet minimize the development of antibiotic resistance.

However, guidelines are one thing, but the practices of physicians and hospitals in Denmark deviate from the guidelines.

In Denmark, the average inpatient with community-acquired pneumonia is treated for 10 days. This is a slippery slope, explains Thomas Benfield, Clinical Professor, Department of Clinical Medicine, University of Copenhagen and attending physician, Department of Infectious Diseases, Amager & Hvidovre Hospital.

“Although antibiotics overall are not dangerous for each individual, over exposure to antibiotics increases society’s risk of developing antibiotic resistance, and this can create huge problems in the future. We therefore need to determine how to get physicians and hospitals to follow the official guidelines for antibiotic treatment,” explains Thomas Benfield.

Thomas Benfield recently published the results of a research collaboration showing that a stewardship programme among physicians can reduce antibiotic use, but the effect of the intervention dissipates once the programme ends.

The research has been published in the International Journal of Infectious Diseases.

Bombarding doctors with mails on antibiotic use

The researchers wanted to determine whether an 8-month information campaign on antibiotic use at several hospitals in Denmark could reduce this to the recommended number of treatment days.

The objective was simple: to investigate whether the probability of being treated with antibiotics for more than 7 days declined during the information campaign compared with the period before the intervention.

The campaign comprised disseminating information to nurses and physicians and nudging, in which the researchers tried to gently persuade the healthcare personnel to only use antibiotics in accordance with the guidelines.

“For example, we sent them many e-mails so that they were constantly aware of how they used antibiotics for people with community-acquired pneumonia,” says Thomas Benfield.

The study included 771 people with community-acquired pneumonia and reduced antibiotic use.

Intervention caused consumption of antibiotics to decline

The results provide food for thought.

The researchers found that hospitals do not follow the guidelines, using antibiotics for many more days than is recommended.

The hospitals also use many broad-spectrum antibiotics even when not needed.

During the stewardship programme, the researchers reduced antibiotic use to almost the recommended amount and duration.

However, they did not achieve all their objectives.

“Although we continually nudged the physicians and nurses, we did not quite achieve the reduction we wanted, and we wondered why not. Our results show that physicians often agree that antibiotic use should be reduced, but when treating each individual, they still prefer to prescribe a little extra to ensure that the infection is eradicated,” explains Thomas Benfield.

One day less treatment substantially reduces antibiotic resistance

Thomas Benfield explains that, as soon as an intervention like this one ends, physicians typically slip back into their old antibiotic habits.

The researchers are therefore also experimenting with various models to determine how they can prevent this from happening.

Many physicians lack evidence on the efficacy of treating for 5 days versus 10 days. Thomas Benfield is obtaining this documentation in clinical trials, in which the researchers and physicians behind the study investigate how 5 days versus 10 days of antibiotic treatment affects breathing.

“Our guidelines are largely based on expert assessment, and this is the lowest level of evidence. We therefore need studies and research results that we can give to the physicians so that they can see that they do not have to treat for 10 days but can settle for 5 days. If we can help to provide this evidence, we can also push development in the right direction. We can substantially reduce the risk of developing antibiotic resistance by shortening 100,000 annual treatments by 1 day,” says Thomas Benfield.

Hospitals should take ownership of following the guidelines

Thomas Benfield hopes that, in the future, antibiotic use will increasingly depend on how the individual person is doing rather than being managed by guidelines on treatment duration.

“I would much rather we examine the patient on the second or third day and assess the need for additional antibiotic treatment rather than try to predict it all on the first day of treatment, not knowing how the patient will react,” explains Thomas Benfield.

He also thinks that the only way to reach the goal of lowering antibiotic use, and thus also lowering the risk of developing antibiotic resistance with all that entails, is to keep raising awareness of the problem.

“The challenge is to get the hospitals to take ownership of the changes in practice when there is no research project to support them. They are obligated to follow the national guidelines, but in the healthcare sector many are competing for the same resources. Although educating healthcare professionals on antibiotic use is not a priority, we can demonstrate that shortening treatment produces the same outcomes. So we are not putting patients’ health at risk by doing the right thing,” concludes Thomas Benfield.

The impact of a stewardship programme on antibiotic administration in community-acquired pneumonia: results from an observational before-after study” has been published in the International Journal of Infectious Diseases. In 2018, the Novo Nordisk Foundation awarded a grant to Thomas Benfield for the project Shortened Antibiotic Treatment in Community-acquired Pneumonia: a Nationwide Danish Randomized Clinical Trial.

Professor of infectious diseases at the Department of Clinical Medicine, University of Copenhagen, and attending physician at the Department of Infect...

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