Antibiotic Scripts Less Common After Internet Training

Larry Hand

August 02, 2013

European physicians who participated in Internet-based training on the use of C-reactive protein (CRP) tests or enhanced patient communications wrote significantly fewer antibiotic prescriptions for patients with acute respiratory tract infections than physicians who did not participate in the training, in a randomized controlled trial.

Paul Little, MD, from the Primary Care and Population Sciences Division, University of Southampton, United Kingdom, and colleagues reported the results of the multinational, cluster, randomized, factorial-controlled trial in an article published online July 31 in the Lancet.

They enrolled participants between February and May 2011 and compared the results with a baseline audit of prescriptions during October to December 2010.

The researchers randomly assigned 246 primary care practices, with 4264 patients, across 6 European countries (Belgium, the Netherlands, Poland, Spain, England, and Wales) to usual care, CRP training, enhanced communication training, or CRP and enhanced communication training together. CRP is predictive of pneumonia, helps to distinguish severities of infection, and can aid in the decision of whether to prescribe antibiotics.

The overall antibiotic prescribing rate during the baseline audit was 55.3%.

After CRP training, the rate of antibiotic prescribing decreased to 33% in the group that received CRP training compared with 48% for no CRP training (adjusted risk ratio [RR], 0.54; 95% confidence interval [CI], 0.42 - 0.69). After enhanced communication training, prescribing decreased to 36% in the training group compared with 45% for the no training group (RR, 0.69; 95% CI, 0.54 - 0.87). However, the combined CRP and communications training produced the greatest reduction (CRP RR, 0.53 [95% CI, 0.36 - 0.74; P < .0001]; enhanced communication, 0.68 [95% CI, 0.50 - 0.89; P = .003]; combined, 0.38 [95% CI, 0.25 - 0.55; P < .0001]).

For patients with symptoms rated moderately bad or worse, the median time to symptom resolution was 5 days for the usual care and CRP groups and 6 days for the enhanced communication group.

Of 30 patients hospitalized, 2 were in the usual care group, 10 were in the CRP group, 6 were in the enhanced-communications group, and 12 were in the combined intervention group. However, hospitalization rates were significantly different only after controlling for clustering, or differences between physicians at the same practice (odds ratio [OR], 2.61; 95% CI, 1.07 - 6.35; P = .034), and nonsignificant after controlling for all potential confounders, including age, sex, and comorbidities (OR, 2.91; 95% CI, 0.96 - 8.85; P = .060).

Increased risks may be balanced against the potential benefits of reduced antibiotic prescribing and reduced antibiotic-associated adverse effects, the researchers write.

The researchers used an Internet-based training tool developed by the Genomics to combat Resistance against Antibiotics in Community-acquired LRTI in Europe (GRACE) consortium, which was translated and acceptable to physicians in several European countries.

"The easily accessible format of internet-based intervention delivery and the success of the interventions across national language and cultural boundaries suggest that these interventions could be implemented widely in many health systems," the researchers conclude.

Although the study was targeted to lower respiratory tract infections, the interventions also lowered antibiotic prescribing for upper tract infections.

In an accompanying commentary, Chris van Weel, MD, PhD, from the Department of Primary and Community Care, Radboud University, Nijmegen, the Netherlands, writes, "These effects of the intervention are in themselves welcome, and I compliment Little and colleagues for undertaking a complex study in real-life general-practice conditions and in multiple countries. The interventions used seem inexpensive, which will make it interesting to find out whether the effects are retained in the long term."

This research was supported by the European Commission Framework 6 Programme and, in the United Kingdom, by the National Institute for Health Research and the Research Foundation Flanders. The authors and the commentator have disclosed no relevant financial relationships.

Lancet. Published online July 31, 2013. Article abstract, Commentary extract

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