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Recommended antimicrobial therapy for common inpatient infections: a comparative review of guidelines across 51 hospital trusts in England
  1. Daniel Pan1,2,
  2. George Hills2,
  3. Ashley Ryan Hamilton2,3,
  4. Tamsin Nash4,
  5. Thomas Hine4,
  6. Sarah Whitehorn4,
  7. Gavin Barlow4
  1. 1 Department of Respiratory Sciences, University of Leicester, Leicester, UK
  2. 2 Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
  3. 3 Leicester School of Pharmacy, De Montfort University, UK, Leicester
  4. 4 Hull York Medical School, John Hughlings Jackson Building, York, UK
  1. Correspondence to Daniel Pan, NIHR Academic Clinical Fellow in Infectious Diseases, Department of Respiratory Sciences, University of Leicester, Leicester, UK; Daniel.pan{at}


Background The number of different antimicrobial recommendations between hospital trusts for the same indication in England is unknown.

Aim We aimed to evaluate the heterogeneity of antimicrobial recommendations for seven common inpatient infections across hospital trusts in England and evaluate changes to recommendations following introduction of national (National Institute for Healthcare and Excellence, NICE) and international (WHO) antimicrobial guidelines.

Methods Guidelines published on the MicroGuide smartphone application were collected from December 2017 to February 2018 and re-evaluated between December 2019 and February 2020. The following indications were assessed: community-acquired pneumonia (CAP) CURB65 score ≥3, hospital-acquired pneumonia (HAP), infective exacerbation of chronic obstructive pulmonary disease (iCOPD), cellulitis, uncomplicated urinary tract infection (uUTI), intra-abdominal infection (IAI) and sepsis of unknown source (SUS). On follow-up, compliance against WHO WATCH antibiotic and NICE recommendations was evaluated.

Results Guidelines were obtained predominantly from England. Antibiotic regimens between hospitals became increasingly diverse across indications in the following order: uUTI, cellulitis, iCOPD, CAP, HAP, IAI and SUS. A piperacillin/tazobactam-based regimen was recommended in HAP (59%), SUS (39%) and IAI (30%). After 2 years, 107 changes were made to 357 antibiotic regimen recommendations; the overall number of regimens using piperacillin–tazobactam and WHO WATCH antibiotics remained similar. Compliance of recommendations with NICE guidelines as follows: iCOPD (100% adherent), uUTI (98%), cellulitis (90%), CAP (43%) and HAP (27%).

Conclusion The heterogeneity of antibiotic recommendations increased as the indicated infection was more severe, with broader underlying bacterial causes. Piperacillin–tazobactam remains favoured in antibiotic regimens, despite not recommended in WHO and NICE guidance.

  • Gastroenterology
  • Gastrointestinal infections
  • Thoracic medicine
  • Respiratory infections
  • Urology
  • Urinary tract infections

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  • Twitter Ashley Hamilton @RyanPharmilton.

  • Acknowledgements The authors would like to thank the developers of MicroGuide without which this study would not be possible.

  • Contributors DP and GB devised the study. DP, GH, ARH, TN, TH and SW collected and analysed the data. DP and GB drafted the first version of the manuscript. All authors contributed to the final version of the manuscript. DP is responsible for the overall content as guarantor.

  • Funding DP is funded by the National Institute for Health Research.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open-access repository. Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplemental information.