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To compare the effectiveness of two strategies to improve antibiotic use in patients with a complicated urinary tract infection. Multicentre cluster randomised unblinded trial. The departments of Internal Medicine and Urology from 19 hospitals in the Netherlands took part in this trial. Based on retrospective patient record investigations we performed baseline measurements on the scores of a validated set of quality indicators for antibiotic use in a minimum of 50 patients with a complicated urinary tract infection per department in 2009. A similar post-trial measurement took place in 2012. In 2010 we randomised the hospitals between 2 improvement strategies: a multifaceted strategy that included results of the baseline measurements, education, reminders and assistance with optional improvement interventions, and a competitive feedback strategy, in which the departments only received results of the baseline measurements and non-anonymous results from the other departments in this study arm. The primary outcome measure was improvement of the quality indicator scores. Secondary outcome measures were determinants of improvement of the indicators. (Netherlands Trial Register: NTR1742) RESULTS: The baseline and post-trial measurements were performed on 1,964 patients and 2,027 patients, respectively. Post-trial measurements revealed a significant, but limited, improvement of several indicators compared with baseline measurements. We found no significant difference in improvement between the two strategies for any indicator. The intensity with which the departments implemented improvement strategies was mostly suboptimal, but intensive implementation of a strategy was associated with greater improvement. The effectiveness of both improvement strategies was comparable, but limited. For real improvement in antibiotic use in patients with complicated urinary tract infections, improvement interventions should be developed and applied by local professionals themselves

Item does not contain fulltext OBJECTIVE: To compare the effectiveness of two strategies to improve antibiotic use in patients with a complicated urinary tract infection. DESIGN: Multicentre cluster randomised unblinded trial. METHOD: The departments of Internal Medicine and Urology from 19 hospitals in the Netherlands took part in this trial. Based on retrospective patient record investigations we performed baseline measurements on the scores of a validated set of quality indicators for antibiotic use in a minimum of 50 patients with a complicated urinary tract infection per department in 2009. A similar post-trial measurement took place in 2012. In 2010 we randomised the hospitals between 2 improvement strategies: a multifaceted strategy that included results of the baseline measurements, education, reminders and assistance with optional improvement interventions, and a competitive feedback strategy, in which the departments only received results of the baseline measurements and non-anonymous results from the other departments in this study arm. The primary outcome measure was improvement of the quality indicator scores. Secondary outcome measures were determinants of improvement of the indicators. (Netherlands Trial Register: NTR1742) RESULTS: The baseline and post-trial measurements were performed on 1,964 patients and 2,027 patients, respectively. Post-trial measurements revealed a significant, but limited, improvement of several indicators compared with baseline measurements. We found no significant difference in improvement between the two strategies for any indicator. The intensity with which the departments implemented improvement strategies was mostly suboptimal, but intensive implementation of a strategy was associated with greater improvement. CONCLUSION: The effectiveness of both improvement strategies was comparable, but limited. For real improvement in antibiotic use in patients with complicated urinary tract infections, improvement interventions should be developed and applied by local professionals themselves.

Guidelines for antimicrobial treatment are important in the process of improving antibiotic use, because they describe appropriate antibiotic use. In this thesis, we demonstrated the value of appropriate antibiotic use (i.e. guideline adherence) in patients with a complicated urinary tract infection (UTI), one of the most prevalent infectious diseases in hospital. Appropriate antibiotic use increases bacterial coverage rates without prescribing unnecessarily broad regimens, which is beneficial for containment of bacterial resistance. Furthermore, appropriate antibiotic use seems to reduce length of hospital stay by more than 2 days and therefore favours patient outcome and health care costs. In current practice, a large variation was shown between departments in the appropriateness of antibiotic use for patients with a complicated UTI. This was to some extent determined by patient characteristics, and only to a limited extent by department or hospital characteristics. No single antibiotic stewardship elements were consistently associated with appropriate antibiotic use. We compared the effectiveness of two different strategies to improve the appropriateness antibiotic use in patients with a complicated UTI. We found that the effectiveness of both strategies was comparable and that better compliance with the strategies was associated with more improvement. Our study emphasize the need for a locally multidisciplinary team of engaged professionals to initiate improvement interventions, as recommended in antimicrobial stewardship programs. Future improvement initiatives should aim to decrease inter-department variation in appropriateness of antibiotic use by focusing on departments with poor baseline performance, as low baseline performance was associated with a larger effect of improvement strategies.