Interventions to improve antibiotic prescribing practices in ambulatory care

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Abstract
The development of resistance to antibiotics by many important human pathogens has been linked to exposure to antibiotics over time. The misuse of antibiotics for viral infections (for which they are of no value) and the excessive use of broad spectrum antibiotics in place of narrower spectrum antibiotics have been well‐documented throughout the world. Many studies have helped to elucidate the reasons physicians use antibiotics inappropriately. To systematically review the literature to estimate the effectiveness of professional interventions, alone or in combination, in improving the selection, dose and treatment duration of antibiotics prescribed by healthcare providers in the outpatient setting; and to evaluate the impact of these interventions on reducing the incidence of antimicrobial resistant pathogens. We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialized register for studies relating to antibiotic prescribing and ambulatory care. Additional studies were obtained from the bibliographies of retrieved articles, the Scientific Citation Index and personal files. We included all randomised and quasi‐randomised controlled trials (RCT and QRCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies of healthcare consumers or healthcare professionals who provide primary care in the outpatient setting. Interventions included any professional intervention, as defined by EPOC, or a patient‐based intervention. Two review authors independently extracted data and assessed study quality. Thirty‐nine studies examined the effect of printed educational materials for physicians, audit and feedback, educational meetings, educational outreach visits, financial and healthcare system changes, physician reminders, patient‐based interventions and multi‐faceted interventions. These interventions addressed the overuse of antibiotics for viral infections, the choice of antibiotic for bacterial infections such as streptococcal pharyngitis and urinary tract infection, and the duration of use of antibiotics for conditions such as acute otitis media. Use of printed educational materials or audit and feedback alone resulted in no or only small changes in prescribing. The exception was a study documenting a sustained reduction in macrolide use in Finland following the publication of a warning against their use for group A streptococcal infections. Interactive educational meetings appeared to be more effective than didactic lectures. Educational outreach visits and physician reminders produced mixed results. Patient‐based interventions, particularly the use of delayed prescriptions for infections for which antibiotics were not immediately indicated effectively reduced antibiotic use by patients and did not result in excess morbidity. Multi‐faceted interventions combining physician, patient and public education in a variety of venues and formats were the most successful in reducing antibiotic prescribing for inappropriate indications. Only one of four studies demonstrated a sustained reduction in the incidence of antibiotic‐resistant bacteria associated with the intervention. The effectiveness of an intervention on antibiotic prescribing depends to a large degree on the particular prescribing behaviour and the barriers to change in the particular community. No single intervention can be recommended for all behaviours in any setting. Multi‐faceted interventions where educational interventions occur on many levels may be successfully applied to communities after addressing local barriers to change. These were the only interventions with effect sizes of sufficient magnitude to potentially reduce the incidence of antibiotic‐resistant bacteria. Future research should focus on which elements of these interventions are the most effective. In addition, patient‐based interventions and physician reminders show promise and innovative methods such as these deserve further study. 改善門診照護中開立抗生素處方做法的介入措施 由於許多重要的人類病原體長期暴露於抗生素因而發展出抗藥性。現在已確實記載世界各地對病毒感染濫用抗生素治療(對於病毒來說它們是沒有價值的)，且過度使用廣效型抗生素來取代窄效型抗生素。許多研究已幫助醫師澄清不當使用抗生素的原因。 系統性回顧文獻以評估單一或合併的專家介入措施對於改善門診機構中健康照護提供者抗生素處方的選擇，劑量及治療期間長短的效果；並評估這些介入措施對於減少抗生素抗藥性病原的發生率。 我們檢索the Cochrane Effective Practice and Organisation of Care Group (EPOC)的專業登記資料庫以尋找有關抗生素處方與門診照護的研究。從檢索的文章書目，科學引文索引及個人檔案獲得其他研究。 我們納入所有關於門診機構中健康照護消費者或健康照護專家提供初級照護的隨機及類隨機對照試驗(randomised及quasirandomised controlled trials(RCT及QRCT))，前後對照研究(controlled before and after studies (CBA))及間斷時間序列(interrupted time series (ITS))研究。介入措施包括任何由EPOC定義的專業的介入措施，或者一個以病人為基礎的介入措施。 兩名回顧作者分別摘錄資料並評估研究品質。 39篇研究評估醫師的紙本教材，稽核與回饋，教育會議，教育推廣訪視，財務及健康系統的改變，醫師提醒，以病人為基礎的介入措施及多面向的介入措施。這些介入措施用來解決過度使用抗生素以治療病毒感染，選擇治療細菌性感染的抗生素如鏈球菌咽炎(streptococcal pharyngitis)與尿道感染，以及使用抗生素的時間來治療如急性中耳炎(acute otitis...