Authors' objectives:

Unnecessary prescribing of antibiotics is a major problem in the US and worldwide, contributing to the problem of antimicrobial resistance (AMR). This review examines the effects of quality improvement strategies on reducing inappropriate prescribing of antibiotics, targeting both prescribing of antibiotics for non-bacterial illnesses ("the antibiotic treatment decision") and prescribing of broad-spectrum antibiotics when narrow-spectrum agents are indicated ("the antibiotic selection decision").

Authors' results and conclusions: Fifty-four studies reporting a total of 74 trials met the inclusion criteria; 34 studies (reporting 41 trials) addressed the treatment decision, and 26 studies (reporting 33 trials) addressed the selection decision. Six studies evaluated both decisions. Study methodologic quality was generally fair. Nearly all studies took place in outpatient primary care clinics. Studies addressing the antibiotic treatment decision: most studies addressed prescribing for acute respiratory infections (ARIs). Interventions were effective at reducing prescribing, with a median absolute effect of -8.9% [interquartile range (IQR) -12.4% to -6.7%]. No individual quality improvement (QI) strategy (or combination of strategies) was more effective at reducing prescribing. Within clinician education, active educational strategies appeared more effective than passive strategies. When extrapolated to a population level, strategies targeting general antibiotic prescribing appeared to reduce antibiotic prescribing more than strategies targeting prescribing for a single condition. Few studies addressed secondary endpoints; patient satisfaction was not worsened by QI interventions, but effects on AMR or costs could not be assessed. Studies addressing the antibiotic selection decision: Interventions targeted prescribing for ARIs or urinary tract infections (UTIs). Interventions were effective, with a median absolute improvement in prescribing of recommended antibiotics of 10.6% (IQR 3.4% to 18.2%). Clinician education alone appeared more effective than education in combination with audit and feedback, but this finding likely represents confounding. Very few studies addressed secondary outcomes.

Authors' recommendations: Quality improvement efforts appear generally effective at reducing both inappropriate treatment with antibiotics and inappropriate selection of antibiotics. While no single QI strategy was more effective than others, active clinician education may be more effective than passive education, particularly for addressing the antibiotic treatment decision. Greater reductions in overall prescribing may be achieved through efforts targeting prescribing for all acute respiratory infections, rather than targeting single conditions. The available evidence is of only fair quality, and further research on the cost-effectiveness and potential harms of these interventions is needed.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.ahrq.gov/clinic/tp/medigaptp.htm

Year Published: 2006

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: United States

Organisation Name: Agency for Healthcare Research and Quality

Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;

Contact Name: martin.erlichman@ahrq.hhs.gov

Contact Email: martin.erlichman@ahrq.hhs.gov

Copyright: Agency for Healthcare Research and Quality (AHRQ)