546 • CID 2005:40 (15 February) • Rubin et al.
M A J O R A R T I C L E
A Multifaceted Intervention to Improve
Antimicrobial Prescribing for Upper Respiratory Tract
Infections in a Small Rural Community
Michael A. Rubin,1Kim Bateman,3Stephen Alder,2Sharon Donnelly,3Gregory J. Stoddard,1and Matthew H. Samore1
1Internal Medicine and
2Family and Preventive Medicine, University of Utah, and
3HealthInsight, Salt Lake City, Utah
inappropriate, and may contribute to antibiotic resistance among community-acquired pathogens, such as Strep-
A multifaceted intervention involving health care professionals and patients was introduced to a
small rural Utah community and included the repetitive use of printed diagnostic and treatment algorithms by
professionals. Data on the quantity and class of antibiotic prescribing, which were collected from multiple sources,
were measured for the intervention period (from January through June) in 2001 and compared with data for the
baseline period during the same months in 2000.
Medicaid claims data revealed that the percentage of patients in the community who received an-
tibiotics for URTIs during the intervention period was 15.6% less than that for the baseline period, whereas the
percentage in the rest of rural Utah was relatively stable, with a 1.5% decrease (
the intervention was on prescribing for acute bronchitis (decreases of 56.1% and 1.7% in the community and
ruralUtah, respectively; )andonprescribingofmacrolides(decreasesof13.4%and0.2%inthecommunityP p .024
and rural Utah, respectively;). Community pharmacy data likewise revealed a 17.5% decrease in the rateP ! .001
of antibiotic prescribing during the intervention period (P ! .001
prescribing (50.9%;). Chart review data, in contrast, revealed no significant decrease in the percentage ofP ! .001
patients with URTI who were prescribed an antibiotic (3.8%;
of 11.2% in macrolide use ().P p .045
A multifaceted intervention involving the repetitive use of printed algorithms resulted inmodest
improvements in antibiotic prescribing for outpatient URTIs, although one data source did not corroborate this.
However, macrolide prescribing decreased sharply, irrespective of the source of data.
Antibiotic prescribing for upper respiratory tract infections (URTIs) is widespread, is often
). The greatest impact ofP p .006
), with the largest decrease observed for macrolide
), although there was a significant decreaseP p .49
Antimicrobial agents are the second most commonly
prescribed group of medications in the United States
. The overwhelming majority of such prescriptions
in community practice are for the treatment of acute
upper respiratory tract infections (URTIs), including
rhinosinusitis, pharyngitis, bronchitis, otitis media,and
nonspecific URTIs , despite the fact that viruses
cause most of these illnesses. This widespread use of
antibiotics has contributed to the spread of antibiotic
Received 14 June 2004; accepted 12 October 2004; electronically published 25
Reprints or correspondence: Dr. Michael A. Rubin, Div. of Clinical Epidemiology,
Dept. of Internal Medicine, University of Utah School of Medicine, 300 N. 1900
East, Rm. AC-230A, Salt Lake City, UT 84132 (Michael.Rubin@hsc.utah.edu).
Clinical Infectious Diseases2005;40:546–53
? 2005 by the Infectious Diseases Society of America. All rights reserved.
resistance among community-acquiredpathogens,such
as Streptococcus pneumoniae.
Numerous interventions to alter antimicrobial pre-
scribing practices have been reported, with varying re-
sults [3–6]. No single intervention appears to have a
superior efficacy, although the use of small-group out-
reach visits (i.e., academic detailing) may be the most
effective strategy for achieving change in physician be-
havior, as demonstrated in numerous studies [6–8].
Many experts now agree that combinations of inter-
ventions are more effective [9–12], and strategies that
target health care professionals and patients (or parents
of young patients) appear to have achieved success at
reducing antimicrobial prescriptions for these predom-
inantly viral conditions [13–17]. Most of these inter-
ventions were centered oneducationalsessionsandma-
terials for health care professionals and patients in
urban and suburban settings.
at Central Police University Library on February 2, 2016
Improving Outpatient Antibiotic Prescribing • CID 2005:40 (15 February) • 553
1. Nelson CR. Drug utilization in office practice: National Ambulatory
Medical Care Survey, 1990. Adv Data 1993;232:1–12.
2. McCaig LF, Hughes JM. Trends in antimicrobial drug prescribing
among office-based physicians in the United States. JAMA 1995;273:
3. Christakis DA, Zimmerman FJ, Wright JA, Garrison MM, Rivara FP,
Davis RL. A randomized controlled trial of point-of-care evidence to
improve the antibiotic prescribing practicesforotitismediainchildren.
4. Beilby J, Marley J, Walker D, Chamberlain N, Burke M. Effect of
changes in antibiotic prescribing on patient outcomes in a community
setting: a natural experiment in Australia. Clin Infect Dis 2002;34:
5. O’Connell DL, Henry D, Tomlins R. Randomised controlled trial of
effect of feedback on general practitioners’ prescribing in Australia.
6. Solomon DH, Van Houten L, Glynn RJ, et al. Academic detailing to
improve use of broad-spectrum antibiotics at an academic medical
center. Arch Intern Med 2001;161:1897–902.
7. Avorn J, Soumerai SB. Improving drug-therapy decisions through ed-
ucational outreach: a randomized controlledtrialofacademicallybased
“detailing.” N Engl J Med 1983;308:1457–63.
8. Ilett KF, Johnson S, Greenhill G, et al. Modification of general prac-
titioner prescribing of antibiotics by use of a therapeutics adviser (ac-
ademic detailer). Br J Clin Pharmacol 2000;49:168–73.
9. Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med
10. Grol R. Personal paper: beliefs and evidence in changing clinical prac-
tice. BMJ 1997;315:418–21.
11. Davis DA, Taylor-Vaisey A. Translating guidelines into practice: a sys-
tematic review of theoretic concepts, practical experience and research
evidence in the adoption of clinical practice guidelines. CMAJ 1997;
12. Smith WR. Evidence for the effectiveness of techniques to change
physician behavior. Chest 2000;118:8S–17S.
13. Gonzales R, Steiner JF, Lum A, Barrett PH Jr. Decreasing antibiotic
use in ambulatory practice: impact of a multidimensionalintervention
on the treatment of uncomplicated acute bronchitis in adults. JAMA
14. Perz JF, Craig AS, Coffey CS, et al. Changes in antibiotic prescribing
for children after a community-wide campaign. JAMA 2002;287:
15. Harris RH, MacKenzie TD, Leeman-Castillo B, et al. Optimizing an-
tibiotic prescribing for acute respiratory tract infections in an urban
urgent care clinic. J Gen Intern Med 2003;18:326–34.
16. Finkelstein JA, Davis RL, Dowell SF, et al. Reducing antibiotic use in
children: a randomized trial in 12 practices. Pediatrics 2001;108:1–7.
17. Belongia EA, Sullivan BJ, Chyou PH, Madagame E, Reed KD, Schwartz
B. A community intervention trial to promote judicious antibiotic use
and reduce penicillin-resistant Streptococcus pneumoniae carriage in
children. Pediatrics 2001;108:575–83.
18. Samore MH, Magill MK, Alder SC, et al. High rates of multiple an-
tibiotic resistance in Streptococcus pneumoniae from healthy children
living in isolated rural communities: association with cephalosporin
use and intrafamilial transmission. Pediatrics 2001;108:856–65.
19. US Census Bureau. Census 2000 data for the State of Utah. Available
at: http://www.census.gov/census2000/states/ut.html. Accessed 16 Au-
20. Centers for Disease Control and Prevention. National campaign for
appropriate antibiotic use. Available at: http://www.cdc.gov/drugres-
istance/community/. Accessed 1 May 2004.
21. Sankoh AJ, Huque MF, Dubey SD. Some comments on frequentlyused
multiple endpoint adjustment methods in clinical trials. Stat Med
22. Greenland S, Rothman K. Introduction to categorical statistics. In:
Rothman K, Greenland S, eds. Modern epidemiology. 2nd ed. Phila-
delphia: Lippincott-Raven Publishers, 1998:249–50.
23. Hennessy TW, Petersen KM, Bruden D, et al. Changes in antibiotic-
prescribing practices and carriage of penicillin-resistant Streptococcus
pneumoniae: a controlled intervention trial in rural Alaska. Clin Infect
24. McCaig LF, Besser RE, Hughes JM. Trends in antimicrobialprescribing
rates for children and adolescents. JAMA 2002;287:3096–102.
25. Halasa NB, Griffin MR, Zhu Y, Edwards KM. Decreased number of
antibiotic prescriptions in office-based settings from 1993 to 1999 in
children less than five years of age. Pediatr Infect Dis J 2002;21:1023–8.
26. Finkelstein JA, Stille C, Nordin J, et al. Reduction in antibiotic use
among US children, 1996–2000. Pediatrics 2003;112:620–7.
27. Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The
diagnosis of strep throat in adults in the emergency room. Med Decis
at Central Police University Library on February 2, 2016