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Research is needed to deliver effective interventions that are ready for implementation into clinical practice. All three trials were small and none considered clinical outcomes or sustainability.

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One trial evaluated different approaches to feedback, one compared different hospital specialties, and one reported that intense feedback was effective in reducing antibiotic use. Three small, hospital-level, cluster-randomised trials were identified. These studies included one before-and-after study, which identified no effect of unsupported clinician-led prescription review on antibiotic use.

Among the 427 studies found, most were uncontrolled evaluations of different approaches to education, decision support, and feedback. Evidence-based tools to support prescribers to stop unnecessary antibiotics do not exist.We searched PubMed, with no language or date restrictions, on Jan 31, 2022, for clinical studies that focused on improving antibiotic use for adults who were admitted to hospital using the terms “anti-bacterial agents therapeutic use” and “antibiotic stewardship”. Consequently, reducing overuse of antibiotics in hospitals requires prescribers to review and, when appropriate, stop unnecessary antibiotic prescriptions.

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Patients who are acutely ill often need antibiotics before full diagnostic information is available. This trial is completed and is registered with ISRCTN, ISRCTN12674243.

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Intervention effects were assessed by use of interrupted time series analyses within each site, estimating overall effects through random-effects meta-analysis, with heterogeneity across prespecified potential modifiers assessed by use of meta-regression. Outcomes were assessed in the modified intention-to-treat population (ie, excluding sites that withdrew before implementation). Co-primary outcomes were monthly antibiotic defined daily doses per adult acute general medical admission (hospital-level, superiority) and all-cause mortality within 30 days of admission (patient level, non-inferiority margin of 5%). The intervention effect was assessed using data from pseudonymised routine electronic health records, ward-level antibiotic dispensing, Clostridioides difficile tests, prescription audits, and an implementation process evaluation. Hospital clusters were randomised to an implementation date occurring at 1–2 week intervals, and the date was concealed until 12 weeks before implementation, when local preparations were designed to start. Hospitals were eligible for inclusion if they admitted adult non-elective general or medical inpatients, had a local representative to champion the intervention, and could provide the required study data. We performed a stepped-wedge, cluster (hospital)-randomised controlled trial using computer-generated sequence randomisation of eligible hospitals in seven calendar-time blocks in the UK.

The Lancet Regional Health – Western Pacific.

The Lancet Regional Health – Southeast Asia.

The Lancet Gastroenterology & Hepatology.

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