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Randomized Controlled Trial
. 2022 Mar 23;74(6):947-956.
doi: 10.1093/cid/ciab602.

Improving Outpatient Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: A Stepped-Wedge Cluster Randomized Trial

Lauren Dutcher  1   2 , Kathleen Degnan  1 , Afia B Adu-Gyamfi  3 , Ebbing Lautenbach  1   2 , Leigh Cressman  2 , Michael Z David  1   2 , Valerie Cluzet  4 , Julia E Szymczak  2 , David A Pegues  1 , Warren Bilker  2 , Pam Tolomeo  2 , Keith W Hamilton  1
Affiliations
Randomized Controlled Trial

Improving Outpatient Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: A Stepped-Wedge Cluster Randomized Trial

Lauren Dutcher et al. Clin Infect Dis. .

Abstract

Background: Inappropriate antibiotic prescribing is common in primary care (PC), particularly for respiratory tract diagnoses (RTDs). However, the optimal approach for improving prescribing remains unknown.

Methods: We conducted a stepped-wedge study in PC practices within a health system to assess the impact of a provider-targeted intervention on antibiotic prescribing for RTDs. RTDs were grouped into tiers based on appropriateness of antibiotic prescribing: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). Providers received education on appropriate RTD prescribing followed by monthly peer comparison feedback on antibiotic prescribing for (1) all tiers and (2) tier 3 RTDs. A χ 2 test was used to compare the proportion of visits with antibiotic prescriptions before and during the intervention. Mixed-effects multivariable logistic regression analysis was performed to assess the association between the intervention and antibiotic prescribing.

Results: Across 30 PC practices and 185 755 total visits, overall antibiotic prescribing was reduced with the intervention, from 35.2% to 23.0% of visits (P < .001). In multivariable analysis, the intervention was associated with a reduced odds of antibiotic prescription for tiers 2 (odds ratio [OR] 0.57; 95% confidence interval [CI] .52-.62) and 3 (OR 0.57; 95% CI .53-.61) but not for tier 1 (OR 0.98; 95% CI .83-1.16).

Conclusions: A provider-focused intervention reduced overall antibiotic prescribing for RTDs without affecting prescribing for infections that likely require antibiotics. Future research should examine the sustainability of such interventions, potential unintended adverse effects on patient health or satisfaction, and provider perceptions and acceptability.

Keywords: antibiotic prescribing; antibiotic stewardship; antimicrobial stewardship; primary care; respiratory tract infections.

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Figures

Figure 1.
Figure 1.
Stepped-wedge interventional study design. Abbreviations: E, educational session; PF, provider feedback.
Figure 2.
Figure 2.
Monthly proportion of visits with antibiotic prescription by cluster. Arrow denotes month of intervention for each cluster.
Figure 3.
Figure 3.
Variation of odds ratios of antibiotic prescription by study month for entire study period. Reference = August.
See this image and copyright information in PMC

References

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