Meta-Analysis

. 2025 Feb 24;80(2):253-262.

doi: 10.1093/cid/ciae604.

Audit and Feedback Interventions for Antibiotic Prescribing in Primary Care: A Systematic Review and Meta-analysis

Alice X T Xu^{1

2}, Kevin Brown^{1

2}, Kevin L Schwartz^{1

2

3}, Soheila Aghlmandi⁴, Sarah Alderson⁵, Jamie C Brehaut^{6

7}, Benjamin C Brown⁸, Heiner C Bucher⁹, Janet Clarkson^{10

11}, An De Sutter¹², Nick A Francis¹³, Jeremy Grimshaw^{6

14}, Ronny Gunnarsson^{15

16

17}, Michael Hallsworth^{18

19}, Lars Hemkens^{9

20

21

22}, Sigurd Høye²³, Tasneem Khan⁵, Donna M Lecky²⁴, Felicia Leung²⁵, Jeremy Leung²⁶, Morten Lindbæk²³, Jeffrey A Linder²⁷, Carl Llor^{28

29

30}, Paul Little¹³, Denise O'Connor³¹, Céline Pulcini^{32

33}, Kalisha Ramlackhan¹, Craig R Ramsay³⁴, Pär-Daniel Sundvall^{15

16

17}, Monica Taljaard^{6

7}, Pia Touboul Lundgren³⁵, Akke Vellinga³⁶, Jan Y Verbakel^{37

38}, Theo J Verheij³⁹, Carl Wikberg^{15

16}, Noah Ivers⁴⁰

Affiliations

¹ Public Health Ontario, Toronto, Ontario, Canada.
² Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
³ Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada.
⁴ Paediatric Research Center, University Children's Hospital Basel (UKBB), Basel, Switzerland.
⁵ Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.
⁶ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
⁷ School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.
⁸ Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, Manchester, United Kingdom.
⁹ Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Basel, Switzerland.
¹⁰ School of Dentistry, University of Dundee, Dundee, United Kingdom.
¹¹ NHS Education for Scotland, Dundee, United Kingdom.
¹² Department of Public Health and Primary Care, Center for Family Medicine UGent, Ghent University, Ghent, Belgium.
¹³ Primary Care Research Centre, University of Southampton, Southampton, United Kingdom.
¹⁴ Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
¹⁵ General Practice / Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
¹⁶ Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Gothenburg, Sweden.
¹⁷ Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden.
¹⁸ The Behavioural Insights Team, Brooklyn, New York, USA.
¹⁹ Center for Social Norms and Behavioral Dynamics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²⁰ Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland.
²¹ Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany.
²² Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA.
²³ Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway.
²⁴ Primary Care & Interventions Unit, HCAI, Fungal, AMR, AMU& Sepsis Division, UK Health Security Agency, London, United Kingdom.
²⁵ Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
²⁶ Faculty of Science, McGill University, Montreal, Quebec, Canada.
²⁷ Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
²⁸ University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain.
²⁹ CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.
³⁰ Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.
³¹ School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
³² Université de Lorraine, APEMAC, Nancy, France.
³³ Université de Lorraine, CHRU-Nancy, Centre régional en antibiothérapie du Grand Est AntibioEst, Nancy, France.
³⁴ Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom.
³⁵ Department of Public Health, Nice University Hospital, Nice, France.
³⁶ CARA Network, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland.
³⁷ Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
³⁸ NIHR Community Healthcare Medtech and IVD cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
³⁹ Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands.
⁴⁰ Women's College Hospital, Toronto, Ontario, Canada.

PMID: 39657007
PMCID: PMC11848270
DOI: 10.1093/cid/ciae604

Meta-Analysis

Audit and Feedback Interventions for Antibiotic Prescribing in Primary Care: A Systematic Review and Meta-analysis

Alice X T Xu et al. Clin Infect Dis. 2025.

. 2025 Feb 24;80(2):253-262.

doi: 10.1093/cid/ciae604.

Authors

Affiliations

¹ Public Health Ontario, Toronto, Ontario, Canada.
² Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
³ Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada.
⁴ Paediatric Research Center, University Children's Hospital Basel (UKBB), Basel, Switzerland.
⁵ Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.
⁶ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
⁷ School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.
⁸ Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, Manchester, United Kingdom.
⁹ Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Basel, Switzerland.
¹⁰ School of Dentistry, University of Dundee, Dundee, United Kingdom.
¹¹ NHS Education for Scotland, Dundee, United Kingdom.
¹² Department of Public Health and Primary Care, Center for Family Medicine UGent, Ghent University, Ghent, Belgium.
¹³ Primary Care Research Centre, University of Southampton, Southampton, United Kingdom.
¹⁴ Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
¹⁵ General Practice / Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
¹⁶ Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Gothenburg, Sweden.
¹⁷ Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden.
¹⁸ The Behavioural Insights Team, Brooklyn, New York, USA.
¹⁹ Center for Social Norms and Behavioral Dynamics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²⁰ Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland.
²¹ Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany.
²² Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA.
²³ Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway.
²⁴ Primary Care & Interventions Unit, HCAI, Fungal, AMR, AMU& Sepsis Division, UK Health Security Agency, London, United Kingdom.
²⁵ Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
²⁶ Faculty of Science, McGill University, Montreal, Quebec, Canada.
²⁷ Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
²⁸ University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain.
²⁹ CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.
³⁰ Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.
³¹ School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
³² Université de Lorraine, APEMAC, Nancy, France.
³³ Université de Lorraine, CHRU-Nancy, Centre régional en antibiothérapie du Grand Est AntibioEst, Nancy, France.
³⁴ Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom.
³⁵ Department of Public Health, Nice University Hospital, Nice, France.
³⁶ CARA Network, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland.
³⁷ Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
³⁸ NIHR Community Healthcare Medtech and IVD cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
³⁹ Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands.
⁴⁰ Women's College Hospital, Toronto, Ontario, Canada.

PMID: 39657007
PMCID: PMC11848270
DOI: 10.1093/cid/ciae604

Abstract

Background: This systematic review evaluates the effect of audit and feedback (A&F) interventions targeting antibiotic prescribing in primary care and examines factors that may explain the variation in effectiveness.

Methods: Randomized controlled trials (RCTs) involving A&F interventions targeting antibiotic prescribing in primary care were included in the systematic review. Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and ClinicalTrials.gov were searched up to May 2024. Trial, participant, and intervention characteristics were extracted independently by 2 researchers. Random effects meta-analyses of trials that compared interventions with and without A&F were conducted for 4 outcomes: (1) total antibiotic prescribing volume; (2) unnecessary antibiotic initiation; (3) excessive prescription duration, and (4) broad-spectrum antibiotic selection. A stratified analysis was also performed based on study characteristics and A&F intervention design features for total antibiotic volume.

Results: A total of 56 RCTs fit the eligibility criteria and were included in the meta-analysis. A&F was associated with an 11% relative reduction in antibiotic prescribing volume (N = 21 studies, rate ratio [RR] = 0.89; 95% confidence interval [CI]: .84, .95; I2 = 97); 23% relative reduction in unnecessary antibiotic initiation (N = 16 studies, RR = 0.77; 95% CI: .68, .87; I2 = 72); 13% relative reduction in prolonged duration of antibiotic course (N = 4 studies, RR = 0.87 95% CI: .81, .94; I2 = 86); and 17% relative reduction in broad-spectrum antibiotic selection (N = 17 studies, RR = 0.83 95% CI: .75, .93; I2 = 96).

Conclusions: A&F interventions reduce antibiotic prescribing in primary care. However, heterogeneity was substantial, outcome definitions were not standardized across the trials, and intervention fidelity was not consistently assessed. Clinical Trials Registration. Prospero (CRD42022298297).

Keywords: antibiotics; audit and feedback; primary care; systematic review.

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Conflict of interest statement

Potential conflicts of interest. The authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Figures

**Figure 1.**
PRISMA flow diagram for the study selection process. Abbreviation: A&F, audit and feedback.

**Figure 2.**
A, Effect estimates of A&F on antibiotic prescribing volume (N = 21) based on RE meta-analysis model (Higgins I² heterogeneity = 97%). B, Effect estimates of A&F on unnecessary antibiotic initiation (N = 16) based on RE meta-analysis model (Higgins I² heterogeneity = 72%). C, Effect estimates of A&F on prolonged antibiotic prescription course (N = 4) based on RE meta-analysis model (Higgins I² heterogeneity = 86%). D, Effect estimates of A&F on broad-spectrum antibiotic selection (N = 17) based on RE meta-analysis model (Higgins I² heterogeneity = 96%). Abbreviations: A&F, audit and feedback; RE, random effects.

**Figure 3.**
Stratified effect estimates of A&F on antibiotic prescribing volume. Abbreviations: A&F, audit and feedback; CI, confidence interval.

See this image and copyright information in PMC

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Audit and Feedback Interventions for Antibiotic Prescribing in Primary Care: A Systematic Review and Meta-analysis

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Audit and Feedback Interventions for Antibiotic Prescribing in Primary Care: A Systematic Review and Meta-analysis

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