Improving antibiotic prescribing in acute respiratory tract infections: Cluster randomized trial from Norwegian general practice (prescription peer academic detailing (Rx-PAD) study)

Department of General Practice/Family Medicine, Institute of Health and Society, University of Oslo, P O Box 1130, Blindern, N-0318 Oslo, Norway.
BMJ (online) (Impact Factor: 17.45). 07/2013; 347(jul26 1):f4403. DOI: 10.1136/bmj.f4403
Source: PubMed


To assess the effects of a multifaceted educational intervention in Norwegian general practice aiming to reduce antibiotic prescription rates for acute respiratory tract infections and to reduce the use of broad spectrum antibiotics.
Cluster randomised controlled study.
Existing continuing medical education groups were recruited and randomised to intervention or control.
79 groups, comprising 382 general practitioners, completed the interventions and data extractions.
The intervention groups had two visits by peer academic detailers, the first presenting the national clinical guidelines for antibiotic use and recent research evidence on acute respiratory tract infections, the second based on feedback reports on each general practitioner's antibiotic prescribing profile from the preceding year. Regional one day seminars were arranged as a supplement. The control arm received a different intervention targeting prescribing practice for older patients.
Prescription rates and proportion of non-penicillin V antibiotics prescribed at the group level before and after the intervention, compared with corresponding data from the controls.
In an adjusted, multilevel model, the effect of the intervention on the 39 intervention groups (183 general practitioners) was a reduction (odds ratio 0.72, 95% confidence interval 0.61 to 0.84) in prescribing of antibiotics for acute respiratory tract infections compared with the controls (40 continuing medical education groups with 199 general practitioners). A corresponding reduction was seen in the odds (0.64, 0.49 to 0.82) for prescribing a non-penicillin V antibiotic when an antibiotic was issued. Prescriptions per 1000 listed patients increased from 80.3 to 84.6 in the intervention arm and from 80.9 to 89.0 in the control arm, but this reflects a greater incidence of infections (particularly pneumonia) that needed treating in the intervention arm.
The intervention led to improved antibiotic prescribing for respiratory tract infections in a representative sample of Norwegian general practitioners, and the courses were feasible to the general practitioners.
Clinical trials NCT00272155.

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Available from: Morten Lindbæk, Mar 12, 2014
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    • "We identified 28 RCT studies containing clinician education. Most studies showed that reduction in antibiotic prescribing was achieved through interventions focused on clinician education programs, such as interactive seminars [14], mailing campaigns [15] [16], small-group education focusing on evidence-based medicine and communication skills [17] [18] [19], educational outreach visit [20] [21] [22] [23] [24], guidelines and leaflets [25] [26] [27] [28] [29] [30], and a combination of these educational strategies [31] [32]. On average, antibiotic prescription of the intervention group was reduced by 34.1% (from 9% to 52%) compared with the control group. "
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    ABSTRACT: Widespread antimicrobial use and concomitant resistance have led to a significant threat to public health. Because inappropriate use and overuse of antibiotics based on insufficient knowledge are one of the major drivers of antibiotic resistance, education about prudent antibiotic use aimed at both the prescribers and the public is important. This review investigates recent studies on the effect of interventions for promoting prudent antibiotics prescribing. Up to now, most educational efforts have been targeted to medical professionals, and many studies showed that these educational efforts are significantly effective in reducing antibiotic prescribing. Recently, the development of educational programs to reduce antibiotic use is expanding into other groups, such as the adult public and children. The investigation of the contents of educational programs for prescribers and the public demonstrates that it is important to develop effective educational programs suitable for each group. In particular, it seems now to be crucial to develop appropriate curricula for teaching medical and nonmedical (pharmacy, dentistry, nursing, veterinary medicine, and midwifery) undergraduate students about general medicine, microbial virulence, mechanism of antibiotic resistance, and judicious antibiotic prescribing.
    Full-text · Article · May 2015
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    • "A previous Cochrane review42 indicated that multifaceted interventions tailored to precise target populations were most likely to have significant effects on prescribing. Recent randomized controlled trials have evaluated multifaceted interventions43,44 with positive effects on reducing antibiotic prescribing rates. However, few studies have been sufficiently powered, designed, or tested interventions with sufficient effect sizes to show an impact on AMR.42 "
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    ABSTRACT: Antimicrobials are an extremely valuable resource across the spectrum of modern medicine. Their development has been associated with dramatic reductions in communicable disease mortality and has facilitated technological advances in cancer therapy, transplantation, and surgery. However, this resource is threatened by the dwindling supply of new antimicrobials and the global increase in antimicrobial resistance. There is an urgent need for antimicrobial stewardship (AMS) to protect our remaining antimicrobials for future generations. AMS emphasizes sensible, appropriate antimicrobial management for the benefit of the individual and society as a whole. Within the English National Health Service (NHS), a series of recent policy initiatives have focused on all aspects of AMS, including best practice guidelines for antimicrobial prescribing, enhanced surveillance mechanisms for monitoring antimicrobial use across primary and secondary care, and new prescribing competencies for doctors in training. Here we provide a concise summary to clarify the current position and importance of AMS within the NHS and review the evidence base for AMS recommendations. The evidence supports the impact of AMS strategies on modifying prescribing practice in hospitals, with beneficial effects on both antimicrobial resistance and the incidence of Clostridium difficile, and no evidence of increased sepsis-related mortality. There is also a promising role for novel diagnostic technologies in AMS, both in enhancing microbiological diagnosis and improving the specificity of sepsis diagnosis. More work is needed to establish an evidence base for interventions to improve public and patient education regarding the role of antibiotics in common clinical syndromes, such as respiratory tract infection. Future priorities include establishing novel approaches to antimicrobial management (eg, duration of therapy, combination regimens) to protect against resistance and working with the pharmaceutical industry to promote the development of new antimicrobials.
    Full-text · Article · May 2014 · Infection and Drug Resistance
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    • "The educational intervention for the providers in the practice was a passive distribution of the guidelines. Future PDSA cycles will include more active methodology, such as: incorporation of relevant cases into the ambulatory morning report series; inclusion of this project into the formal residency program quality improvement series; provider report cards; and consideration of a peer academic detailing program, which was recently shown effective in improving antibiotic prescribing in acute respiratory tract infections (22). "
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    ABSTRACT: Upper respiratory infections, acute sinus infections, and sore throats are common symptoms that cause patients to seek medical care. Despite well-established treatment guidelines, studies indicate that antibiotics are prescribed far more frequently than appropriate, raising a multitude of clinical issues. The primary goal of this study was to increase guideline adherence rates for acute sinusitis, pharyngitis, and upper respiratory tract infections (URIs). This study was the first Plan-Do-Study-Act (PDSA) cycle in a quality improvement program at an internal medicine resident faculty practice at a university-affiliated community hospital internal medicine residency program. To improve guideline adherence for respiratory infections, a package of small-scale interventions was implemented aimed at improving patient and provider education regarding viral and bacterial infections and the necessity for antibiotics. The data from this study was compared with a previously published study in this practice, which evaluated the adherence rates for the treatment guidelines before the changes, to determine effectiveness of the modifications. After the first PDSA cycle, providers were surveyed to determine barriers to adherence to antibiotic prescribing guidelines. After the interventions, antibiotic guideline adherence for URI improved from a rate of 79.28 to 88.58% with a p-value of 0.004. The increase of adherence rates for sinusitis and pharyngitis were 41.7-57.58% (p=0.086) and 24.0-25.0% (p=0.918), respectively. The overall change in guideline adherence for the three conditions increased from 57.2 to 78.6% with the implementations (p<0.001). In planning for future PDSA cycles, a fishbone diagram was constructed in order to identify all perceived facets of the problem of non-adherence to the treatment guidelines for URIs, sinusitis, and pharyngitis. From the fishbone diagram and the provider survey, several potential directions for future work are discussed. Passive interventions can result in small changes in antibiotic guideline adherence, but further PDSA cycles using more active methodologies are needed.
    Full-text · Article · Feb 2014
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