Intervention to improve the quality of antimicrobial prescribing for urinary tract infection: a cluster randomized trial

Abstract

Background: Overuse of antimicrobial therapy in the community adds to the global spread of antimicrobial resistance, which is jeopardizing the treatment of common infections.

Methods: We designed a cluster randomized complex intervention to improve antimicrobial prescribing for urinary tract infection in Irish general practice. During a 3-month baseline period, all practices received a workshop to promote consultation coding for urinary tract infections. Practices in intervention arms A and B received a second workshop with information on antimicrobial prescribing guidelines and a practice audit report (baseline data). Practices in intervention arm B received additional evidence on delayed prescribing of antimicrobials for suspected urinary tract infection. A reminder integrated into the patient management software suggested first-line treatment and, for practices in arm B, delayed prescribing. Over the 6-month intervention, practices in arms A and B received monthly audit reports of antimicrobial prescribing.

Results: The proportion of antimicrobial prescribing according to guidelines for urinary tract infection increased in arms A and B relative to control (adjusted overall odds ratio [OR] 2.3, 95% confidence interval [CI] 1.7 to 3.2; arm A adjusted OR 2.7, 95% CI 1.8 to 4.1; arm B adjusted OR 2.0, 95% CI 1.3 to 3.0). An unintended increase in antimicrobial prescribing was observed in the intervention arms relative to control (arm A adjusted OR 2.2, 95% CI 1.2 to 4.0; arm B adjusted OR 1.4, 95% CI 0.9 to 2.1). Improvements in guideline-based prescribing were sustained at 5 months after the intervention.

Interpretation: A complex intervention, including audit reports and reminders, improved the quality of prescribing for urinary tract infection in Irish general practice.

Trial registration: ClinicalTrials.gov, no. NCT01913860.

Figure 1:

CONSORT flow diagram for the Supporting the Improvement and Management of Prescribing (SIMPle) study. GP = general practitioner. *Invitations were extended to practices that met the initial inclusion criterion until the target number of practices (n = 30) was reached. The remaining 14 practices met the eligibility criteria, but were not needed and hence were not invited.

Figure 2:

Percentage of practice contacts in which nitrofurantoin was prescribed (for practice contacts with prescribing of any antimicrobial), before, during and after the intervention in each study arm. CI = confidence interval.