Intervention Increases UTI Antibiotic Prescribing Quality

Marcia Frellick

November 18, 2015

An intervention that included additional information for groups of general practice physicians significantly improved the percentage appropriately prescribing antibiotics for urinary tract infections (UTIs), according to a new study.

"Clear, contextualized, practice-specific information in the form of feedback reports is a highly efficient method to investigate and change the antimicrobial prescribing behaviour of general practitioners," Akke Vellinga, PhD, epidemiologist in the School of Medicine at National University of Ireland in Galway, and coauthors write.

"Improvements in guideline-based prescribing were sustained at 5 months after the intervention," they report.

These findings were published online November 16 in the Canadian Medical Association Journal.

For the study, 71 physicians in 30 general practices in Ireland were randomly assigned to one of three groups to test levels of interventions to change prescribing behavior.

All the physicians were included in a workshop on coding for UTIs. Then participants were randomly assigned either to the control group (coding workshop only) or to one of two groups that received the intervention. Intervention groups A and B participated in an added workshop on prescribing guidelines and received results of monthly follow-up audits for the 6 months of the intervention.

Group B received additional evidence supporting delayed prescribing in the case of suspected UTI.

Compared with the control group, overall prescribing of a first-line antibiotic increased 24.5% in group A and 18.4% in group B. Prescribing of nitrofurantoin, the preferred first-line option, increased by 37.5% in group A and 32.7% in group B, but remained stable in the control group.

However, an unexpected (and unexplained) consequence of the intervention was an increase in overall prescribing of antibiotics relative to the control group (group A adjusted odds ratio, 2.2 [95% confidence interval, 1.2 to 4.0]; group B adjusted odds ratio, 1.4 [95% confidence interval, 0.9 - 2.1]).

"[I]t was not possible to conclude whether this was clinically appropriate or an unwanted consequence," the authors write. They suggest that if the increase in prescribing is caused by more prescribing of nitrofurantoin, the potential harm may not be such a problem because there is little evidence of acquired resistance with this antibiotic.

In an accompanying commentary, Sarah Tonkin-Crine, PhD, and Kyle Knox, MBChB, researchers at the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom, said studies should consider unintended consequences when trying to change behavior.

"Interventions that are successful in changing knowledge and attitudes often change intentions to prescribe, which, in an environment that supports nonprescription, can lead to a change in prescribing behaviour," they write.

They add that the results were promising and show that general practitioners can play an important role in preventing antibiotic resistance, but they would be interested to see whether the improvement could be replicated in generalized populations.

They also note that they could not ascertain the precise effect the information on delayed prescribing contributed.

"[T]he effect of delayed prescribing, the only difference between the two intervention arms, was measured indirectly. Therefore, the effect of education about delayed prescribing on general practitioners' actual prescribing is unclear," the commentators conclude.

The study was funded by the Health Research Board of Ireland. Additional funding was obtained for the multimedia applications through the Knowledge Exchange and Dissemination Scheme from the Health Research Board. After this study, a coauthor became an employee of Novartis Ireland. The authors and commentators have disclosed no relevant financial relationships.

CMAJ. Published online November 16, 2015. Article full text

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