Effects of a multimodal intervention in primary care to reduce second line antibiotic prescriptions for urinary tract infections in women: parallel, cluster randomised, controlled trial

Abstract

Objectives: To evaluate whether a multimodal intervention in general practice reduces the proportion of second line antibiotic prescriptions and the overall proportion of antibiotic prescriptions for uncomplicated urinary tract infections in women.

Design: Parallel, cluster randomised, controlled trial.

Setting: General practices in five regions in Germany. Data were collected between 1 April 2021 and 31 March 2022.

Participants: General practitioners from 128 randomly assigned practices.

Interventions: Multimodal intervention consisting of guideline recommendations for general practitioners and patients, provision of regional data for antibiotic resistance, and quarterly feedback, which included individual first line and second line proportions of antibiotic prescribing, benchmarking with regional or supra-regional practices, and telephone counselling. Participants in the control group received no information on the intervention.

Main outcome measures: Primary outcome was the proportion of second line antibiotics prescribed by general practices, in relation to all antibiotics prescribed, for uncomplicated urinary tract infections after one year between the intervention and control group. General practices were randomly assigned in blocks (1:1), with a block size of four, into the intervention or control group using SAS version 9.4; randomisation was stratified by region. The secondary outcome was the prescription proportion of all antibiotics, relative within all cases (instances of UTI diagnosis), for the treatment of urinary tract infections after one year between the groups. Adverse events were assessed as exploratory outcomes.

Results: 110 practices with full datasets identified 10 323 cases during five quarters (ie, 15 months). The mean proportion of second line antibiotics prescribed was 0.19 (standard deviation 0.20) in the intervention group and 0.35 (0.25) in the control group after 12 months. After adjustment for preintervention proportions, the mean difference was -0.13 (95% confidence interval -0.21 to -0.06, P<0.001). The overall proportion of all antibiotic prescriptions for urinary tract infections over 12 months was 0.74 (standard deviation 0.22) in the intervention and 0.80 (0.15) in the control group with a mean difference of -0.08 (95% confidence interval -0.15 to -0.02, P<0.029). No differences were noted in the number of complications (ie, pyelonephritis, admission to hospital, or fever) between the groups.

Conclusions: The multimodal intervention in general practice significantly reduced the proportion of second line antibiotics and all antibiotic prescriptions for uncomplicated urinary tract infections in women.

Trial registration: German Clinical Trials Register (DRKS), DRKS00020389.

Fig 1

Flow diagram of participating practices throughout the trial. The final analysis included 57 practices in the intervention group and 53 practices in the control group. Q=quarter

Fig 2

Proportions of second line antibiotic prescriptions in Qb-Q4. Percentiles: 10th (dashed line), 50th (solid line), and 90th percentile (dotted line). Q=quarter; Qb=baseline quarter

Fig 3

Relative frequencies of antibiotic agents in the control and intervention group in Qb and Q4. GPs=general practices; Q=quarter; Qb=baseline quarter*

Fig 4

Mean prescription proportions of second line antibiotics by quarter