Educational interventions to improve prescription and dispensing of antibiotics: a systematic review

Roque, Fátima; Herdeiro, Maria Teresa; Soares, Sara; Teixeira Rodrigues, António; Breitenfeld, Luiza; Figueiras, Adolfo

doi:10.1186/1471-2458-14-1276

BMC Public Health

Table 2 Interventions to improve antibiotic use in primary care

From: Educational interventions to improve prescription and dispensing of antibiotics: a systematic review

Author (year)	Study design (a)	Program description		Baseline and follow-up			Analysis (e)	Results (f)
		Disease (b)	Intervention type (c,d)	Baseline	Intervention period	Follow-up
Dollman, WB (2005) [20]	1	URTI	IG: 1, 2, 8	5 months	5 months	___	2	T (+)
Dollman, WB (2005) [20]	1	URTI	CG: 0	5 months	5 months	___	2	T (+)
Hrisos, S (2008) [21]	4	URTI	IG1: 3	___	3 months	___	3	At/Bh (+)
			IG2: 3
			IG1 + 2: 3
			CG: 0
Hennessy, TW (2002) [22]	3	RTI	IG: 8, 2	2 months	12 months (6 each year of intervention)	2 months	2, 3	T (+)
Hennessy, TW (2002) [22]	3	RTI	CG: 0	2 months	12 months (6 each year of intervention)	2 months	2, 3	T (+)
Rubin, MA (2005) [23]	2	URTI	IG: 1, 2, 8, 9	6 months	6 months	___	2, 3	T (+)
Rubin, MA (2005) [23]	2	URTI	CG: 0	6 months	6 months	___	2, 3	Ga (+)
Naughton, C (2009) [24]	4	RTI	IG1: 3, 4	12 months	___	12 months	2, 3	T (+) (−)^a
Naughton, C (2009) [24]	4	RTI	IG2: 3	12 months	___	12 months	2, 3	Ga (+) (−)^a
Chazan, B (2007) [25]	1	Infectious disease	IG1: 1, 2	4 months	4 months	___	2, 3	T (+)
Chazan, B (2007) [25]	1	Infectious disease	IG2: 1, 2, 8	4 months	4 months	___	2, 3	T (+)
Briel, M (2005) [26]	4	ARTI	IG1: 1,2	___	5 months	___	1	T (+)
			IG2: 1,2
			CG: 0
Monette, J (2007) [27]	4	Lower RTI	IG: 1, 3	3 months	2 x 3 months	3 months	5, 6	Ga (+)
		UTI	CG: 0
		Skin and soft-tissue infections septicemia	CG: 0
Enriquez-Puga, A (2009) [28]	4	___	IG: 1, 3, 4	2 periods of 6 months	6 months	24 months	5, 6	Ga (−)
Bjerrum, L (2006) [29]	2	RTI	IG: 2, 3, 10	3 weeks during 3 months	3 weeks during 3 months	___	1, 2	T (+)
Bjerrum, L (2006) [29]	2	RTI	CG: 0	3 weeks during 3 months	3 weeks during 3 months	___	1, 2	Ga (+)
Mcisaac, WJ (2002) [30]	4	Sore throat	IG: 1, 5	___	___	___	1	T (−)
Mcisaac, WJ (2002) [30]	4	Sore throat	CG: 0	___	___	___	1	Ga (−)
Wheeler, JG (2001) [31]	1	Viral infections	IG: 2, 8, 9	1 week	3 weeks during 3 years	6 months (qualitative)	3	T (−)
Wheeler, JG (2001) [31]	1	Viral infections	IG: 2, 8, 9	1 week	3 weeks during 3 years	6 months (qualitative)	3	At/Bh (+)
Juzych, NS (2005) [32]	3	URTI	IG: 1, 2, 8	4.5 months	4.5 months	___	2, 3	Pa (+) (−)^b
Juzych, NS (2005) [32]	3	URTI	CG: 0	4.5 months	4.5 months	___	2, 3	T (+)
Smeets, HM (2009) [33]	2	RTI	IG: 2, 3, 8	6 months	6 months	6 months (one year later)	5, 6	T (−)
			IG: 2, 3, 8					Ga (−)
			CG: 0					Ga (−)
Mandryk, JA (2006) [34]	1	URTI	IG: 1, 2, 3, 4	33 months	51 months	___	2	Ga (+)
Mandryk, JA (2006) [34]	1	URTI	IG: 1, 2, 3, 4	33 months	51 months	___	2	T (+)
Stille, CJ (2008) [35]	4	RTI	IG: 1, 2, 8	---	---	6 months	1	At/Bh (+) (−)^c
Stille, CJ (2008) [35]	4	RTI	CG: 0	---	---	6 months	1	At/Bh (+) (−)^c
Finkelstein, JA (2001) [36]	4	Otitis media	IG: 1, 2, 3, 8	12 months	12 months	___	2, 3	T (+)
		Pharyngitis	CG: 0
		Sinusitis
		Cold
		Bronchitis
Altiner, A (2007) [37]	4	Acute cough	IG: 4, 8	3 months	___	3 months after 6 weeks 3 months after 1 year after	5, 6	T (+)
Altiner, A (2007) [37]	4	Acute cough	CG: 0	3 months	___	3 months after 6 weeks 3 months after 1 year after	5, 6	T (+)
Légaré, F (2010) [38]	4	Acute RI	IG: 1, 2	___	___	___	2, 3	T (+)
Légaré, F (2010) [38]	4	Acute RI	CG: 0	___	___	___	2, 3	T (+)
Kiang, KM (2005) [39]	1	Respiratory illnesses	IG: 1, 2, 8	___	___	___	2, 3	Ga (+)
Kiang, KM (2005) [39]	1	Respiratory illnesses	IG: 1, 2, 8	___	___	___	2, 3	At/Bh (+)
Mohagheghi, MA [40]	4	___	IG: 2	60 months	___	3 months afterwards 1 year afterwards	2, 3	T (+) (−)^d
Mohagheghi, MA [40]	4	___	CG: 0	60 months	___	3 months afterwards 1 year afterwards	2, 3	T (+) (−)^d
Irurzun, C (2005) [41]	1	Pharyngitis and tonsillitis	IG: 1, 2, 3, 4, 10	___	12 months	___	2	T (+)
Irurzun, C (2005) [41]	1	Pharyngitis and tonsillitis	IG: 1, 2, 3, 4, 10	___	12 months	___	2	Ga (+)
Chalker, J (2005) [42]	5	___	IG: 2, 4, 11	___	___	3x3 months (one month after each intervention)	1	T (+) (−)^e
Chalker, J (2005) [42]	5	___	CG: 0	___	___	3x3 months (one month after each intervention)	1	T (+) (−)^e
Finkelstein, JA (2008) [43]	4	___	IG: 1, 2, 3, 8	24 months	6 months during 3 years	___	2, 3	T (+) (−)^f
Finkelstein, JA (2008) [43]	4	___	CG: 0	24 months	6 months during 3 years	___	2, 3	Ga (+)
Chuc, NTK (2002) [44]	4	ARTI	IG: 2, 4, 11	___	___	___	2, 3	T (+)
Chuc, NTK (2002) [44]	4	ARTI	IG: 2, 4, 11	___	___	___	2, 3	Qh (+)
Belongia, EA (2001) [45]	3	ARTI	IG: 1, 2, 8	6 months	___	6 months (every two years)	7, 8	T (+)
Belongia, EA (2005) [46]	2	___	IG: 1, 2, 8, 9	12 months	48 months	___	3, 4	T (+) (−)^g
Greene, RA (2004) [47]	1	Acute sinusitis	IG: 1, 2, 3, 13	22 months	14 months	___	2	Ga (+)
Greene, RA (2004) [47]	1	Acute sinusitis	IG: 1, 2, 3, 13	22 months	14 months	___	2	T (+)
Teng, CL (2007) [48]	2	URTI and others	IG: 1, 2, 4	3 months	___	3 months	2	T (+)
Awad, AI (2006) [49]	4	___	CG: 0	___	___	1 and 3 months afterwards	2, 3	T (+)^h
			IG1: 1, 3					Ga (+)
			IG2: 2, 3
			IG3: 3, 4
Welschen, I (2004) [50]	4	ARTI	IG: 1, 2, 3, 8	3 months	___	3 months	2, 3	T (+)
Gonzales, R (2004) [51]	2	ARTI	IG: 1, 8	4 months	4 months (study period)		2, 3	T (+) (−)ⁱ
Colomina Rodríguez, J (2010) [52]	1	___	IG: 1, 2, 6, 8	48 months	36 months	24 months	5	T (+)
Colomina Rodríguez, J (2010) [52]	1	___	IG: 1, 2, 6, 8	48 months	36 months	24 months	5	Ga (+)
Hickman, DE (2003) [53]	4	Acute bronchitis	IG: 1, 2, 8	6 months	___	6 months	2, 3	T (+)
Hickman, DE (2003) [53]	4	Acute bronchitis	CG: 0	6 months	___	6 months	2, 3
Coenen, S (2004) [54]	4	Acute cough	IG: 1, 4	3 months	1 month (without outcomes)	___	2,3	T (+)
Coenen, S (2004) [54]	4	Acute cough	IG: 0	3 months	1 month (without outcomes)	___	2,3	Ga (+) (−)^j
Perz, JF (2002) [55]	1	___	IG: 1, 2, 8, 9	12 months	12 months	12 months	5,6	T (+)
Perz, JF (2002) [55]	1	___	CG: 0	12 months	12 months	12 months	5,6	T (+)
Sondergaard, J (2003) [56]	4	RTI	IG: 1, 3	3 periods of 3 months	3 periods of 3 months	3 months (not shown)	2,3	T (−)
Sondergaard, J (2003) [56]	4	RTI	CG: 1	3 periods of 3 months	3 periods of 3 months	3 months (not shown)	2,3	Ga (−)
Doyne, EO (2004) [57]	4	___	IG: 1, 2, 3, 8	12 months	12 months	___	2,3	T (+) (−)^k
			CG1: 1, 3
			CG: 1
Bauchner, H (2006) [58]	5	Acute otitis media	IG: 1, 2, 3	___	___	___	1	Ga (+) (−)^L
Bauchner, H (2006) [58]	5	Acute otitis media	CG: 2	___	___	___	1	Ga (+) (−)^L
Christakis, DA (2001) [59]	4	Acute otitis media	IG: 6	7 months	8 months	___	2,3	T (−)
Christakis, DA (2001) [59]	4	Acute otitis media	CG: 0	7 months	8 months	___	2,3	Ga (+)
Småbrekke, L (2002) [60]	2	Acute otitis media	IG: 1, 2, 8	4 months	4 months	___	2,3	T (+)
Småbrekke, L (2002) [60]	2	Acute otitis media	CG: 0	4 months	4 months	___	2,3	Ga (+)
Bjerrum, L (2011) [61]	1	RTI	IG = 2, 3, 9, 10	3 weeks (x2years)	3 weeks (x1 year)	___	2, 3	T (+)
Bjerrum, L (2011) [61]	1	RTI	IG = 2, 3, 9, 10	3 weeks (x2years)	3 weeks (x1 year)	___	2, 3	Ga (+)
Regev-Yochay, G (2011) [62]	4	___	IG = 2	2 years	1 year	___	2, 3	T (+)
Regev-Yochay, G (2011) [62]	4	___	CG = 0	2 years	1 year	___	2, 3	Ga (+)
Llor, C (2011) [63]	4	Pharyngitis	IG1 = 2, 8, 10	15 days	15 days	___	2, 3	T (+)
Llor, C (2011) [63]	4	Pharyngitis	IG2 = 2, 8, 10 (sem)	15 days	15 days	___	2, 3	T (+)
Weiss, K (2011) [64]	1	___	IG = 1	2 years	7 years	___	2, 3	T (+)
Weiss, K (2011) [64]	1	___	CG = 0	2 years	7 years	___	2, 3	T (+)
Llor, C (2011) [65]	4	Acute pharyngitis	IG = 1, 10	___	___	___	1	Ga (+)
Llor, C (2011) [65]	4	Acute pharyngitis	CG = 1	___	___	___	1	Ga (+)
McKay, RM (2011) [66]	1	___	IG = 1, 2, 8, 9	9 years	3 years	___	2	Pa (+) (−)^m

^a In[24], significantly positive in post-intervention period but no significant change post-follow-up.
^b In[32], while prescriptions for pharyngitis, otitis media and URTI decreased significantly post-intervention, the decrease in the case of bronchitis was not as significant.
^c In[35], comparison between attitudes, knowledge and behavior of physicians in the intervention versus the control group showed no significant differences. Physicians in the intervention group reported that they had changed their prescribing in the preceding 3 years.
^d In[40], after one year, there was a reduction in the percentage of antibiotic prescribing in the intervention group but this was not statistically different from the control group.
^e In[42], interventions resulted in improved antibiotic use, which was statistically significant in the Hanoi but not in the Bangkok study.
^f In[43], there was no significant decrease in one age group (3–24 months).
^g In[56], the reduction in antibiotic prescribing by pediatricians was greater in the control than in the intervention group.
^h In[49], audit and feedback combined with academic detailing or seminars appeared to be more effective in changing antibiotic prescribing practices than audit and feedback alone.
ⁱ In[51], there was a moderate decrease in total antibiotics prescribed but this was not statistically significant.
^j In[54], appropriate antibiotic prescribing improved post-intervention but did not prove statistically significant.
^k In[57], the prescribing rate decreased in all groups but there were no statistically significant differences between groups.
^L In[58], adherence was high though not statistically significant in the intervention group, but, in second episodes there were no differences in adherence, between groups.
^m In[66], utilization rates for acute bronchitis are at the same level as when intervention began, but other acute respiratory tract infections declined.
(a) Disease: URTI – upper respiratory tract infections; RTI – respiratory tract infections; ARTI – acute respiratory tract infections; UTI – urinary tract infections.
(b) Study design (SD): (1) before/after studies; (2) – nonrandomized controlled trial without cross-contamination control; (3) – nonrandomized controlled trial with cross-contamination control; (4) - randomized controlled trial without cross-contamination control; (5) - randomized controlled trial with cross-contamination control.
(c) IG – intervention group; CG – control group.
(d) Type of intervention (TI): (0) no intervention; (1) dissemination of printed/audiovisual educational materials (mailed printed matter; protocols and guidelines; self-instruction materials; drug bulletins); (2) group education, including group-session rounds, conferences, lectures, seminars and tutorials; (3) feedback of physician prescribing patterns (individually or including a comparison of these patterns with peer behavior and/or accepted standards) or feedback of patient-specific lists of prescribed medication; (4) individual outreach visits; (5) reminders at the time of prescribing; (6) computer-assisted decision-making systems; (7) formulary-control/restrictive formulary process; (8) patient education (pamphlets); (9) patient education (videotapes); (10) workshops on rapid tests / introduction of Rapid Antigen Detection Tests (RADTs) in consulting offices; (11) enforcement of regulations; (12) prescription feedback with recommendations to modify it by pharmacists and/or infectious-disease physicians; (13) financial incentives.
(e) Type of data-analysis (T): (1) comparison of post-test values between groups; (2) comparison of pre- and post-values within each group; (3) comparison of pre- and post-values between groups; (4) comparison of follow-up values between groups; (5) comparison of pre-, post- and follow-up values within each group; (6) comparison of pre-, post- and follow-up values between groups.
(f) Results analyzed (R): (T) total antibiotics prescribed/dispensed; (Ga) choice of appropriate antibiotics/adherence to antibiotic guidance according to guideline algorithms, including dosages and routes of administration; (Pa) prescription rate per disease; (At/Bh) attitudes and behavior; (Qph) quality of pharmacy practice.

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