Improving Antimicrobial Prescribing in Geriatric Wards: A Prospective Quality Improvement Project

Introduction
Older people are vulnerable to antimicrobial-related harm owing to frailty, polypharmacy, acute kidney injury, Clostridioides difficile infection, and drug interactions. National guidance recommends documenting the indication and stop/review date for all antimicrobial prescriptions to support antimicrobial stewardship. With the transition from paper drug charts to electronic prescribing, documentation of antibiotic indication within prescribing notes (P-notes) is no longer routinely prompted, increasing the risk of inconsistent documentation. We aimed to improve documentation of antibiotic indications using P-notes while maintaining high stop-date documentation across geriatric wards.

Method
A prospective two-cycle quality improvement project was conducted across four geriatric wards at Queen Elizabeth Hospital Birmingham. Baseline data were collected between 2–11 February 2026 and repeated following intervention between 27 April–6 May 2026. All active antibiotic prescriptions were included. Interventions were multifaceted, comprising of multidisciplinary teaching, reminder emails, electronic messaging, posters, incorporation into resident doctor induction, and pharmacy engagement. Primary outcomes were documentation of antibiotic indication in P-notes and stop-date documentation.

Results
A total of 105 antibiotic prescriptions were reviewed in Cycle 1 and 83 prescriptions in Cycle 2. Documentation of antibiotic indication within P-notes increased significantly following intervention from 5% (5/105) to 46% (38/83) (χ²=44.2, p<0.001). Stop-date documentation remained consistently high, with 97% (102/105) compliance in Cycle 1 and 94% (78/83) in Cycle 2, with no significant difference between cycles (χ²=1.14, p=0.29). Pharmacy staff contributed to 47% of documented P-notes, demonstrating the value of multidisciplinary antimicrobial stewardship. Despite the improvement, 54% of prescriptions still lacked a documented P-note, highlighting ongoing opportunities for improvement.

Conclusion
Simple, low-cost educational and multidisciplinary interventions significantly improved documentation of antibiotic indications while maintaining excellent stop-date documentation. Embedding indication documentation into routine prescribing practice, alongside electronic prescribing prompts, could further strengthen antimicrobial stewardship and improve medication safety for older people.