Evaluating academic detailing as an antibiotic stewardship intervention in primary healthcare settings in Croatia

Abstract

Background: Acute respiratory tract infections are common in primary healthcare care settings and frequently result in antibiotic prescriptions, despite being primarily viral. There is scarcity of research examining impact of academic detailing (AD) intervention on prescribing practices for these infections in resource-constrained healthcare settings like southeastern Europe. Therefore aim of this study was to evaluate impact of AD intervention as an antimicrobial stewardship measure on antibiotic prescribing for acute respiratory tract infections in primary setting in Croatia which is located in southeastern Europe. Secondary goal included examining incidence of Clostridioides difficile infections (CDI) which are often associated with antibiotic consumption.

Methods: AD intervention was implemented from 1st to 30th April 2020 and led by hospital healthcare professionals (infectious disease physician, clinical microbiology physician and clinical pharmacist). They focused on enhancing prescribing behaviors of primary care physicians (PCPs) by presenting local data, supplemented by examples from everyday practice, research and guidelines highlighting negative consequences of imprudent antibiotic use. This feasibility quasi-experimental study had two control groups in two counties. Impact of AD intervention was assessed by analyzing antibiotic prescription patterns using log-linear model, adjusting for seasonality. Study focused on prescribed daily defined doses (DDD) per day among PCPs pre-intervention (from 01st January 2018 to 31st March 2020) and post-intervention (from 1st May 2020 to 31st December 2022).

Results: Data was collected from sixteen out of fifty-seven eligible PCPs with mean 29 years (SD 11.38) in practice. Statistically significant difference results (p < 0.05) favored AD intervention, leading to 30% decline in antibiotic prescribing in adjusted DDD per day for acute pharyngitis (21.14 post-intervention/30.27 pre-intervention), 33% decline for acute tonsilitis (24.91/37.38), 23% decline for acute upper respiratory infection (21.26/27.62) and 36% decline for acute bronchitis (8.13/12.77). Although there was 14% decline for acute sinusitis post-intervention, it did not reach statistical significance (30.96/35.93) (p = 0.617). Incidence of CDI cases decreased in investigated county while in control county stayed the same. Inter-county difference in these changes was not statistically significant (ratio = 0.749, 95% CI, 0.460-1.220; p = 0.246).

Conclusions: This feasibility study showed reductions in antibiotic prescribing for acute respiratory tract infections, emphasizing the efficacy of targeted, educator-led programs. Tailored healthcare strategies are vital, especially in Croatia and southeastern Europe, for promoting sustainable practices and addressing antimicrobial resistance challenges.

Keywords: Academic detailing; Acute respiratory tract infections; Antibiotic prescribing; Antimicrobial resistance; Antimicrobial stewardship; Feasibility study; Primary care.

Fig. 1

A Part A of the figure illustrates the mean adjusted defined daily dose (DDD) of antibiotics prescribed per day for the diagnosis of acute sinusitis, acute pharyngitis, acute tonsillitis, acute upper respiratory infections, and acute bronchitis. The data is presented before (pre-intervention period from 01st January 2018 to 31st March 2020) and after (post-intervention period from 1st May 2020 to 31st December 2022) the implementation of an academic detailing (AD) intervention across three distinct groups: participating primary care physicians (PCPs) in Koprivnica-Krizevci county (KKC), non-participating PCPs in KKC, and all (non-participating) PCPs in Bjelovar-Bilogora county (BBC). The error bars in the graph represent the 95% confidence interval (CI). Additionally, the statistical significance of the group-wise comparison of mean adjusted DDD/day pre- and post-intervention periods are denoted above the columns of each respective group with the corresponding p value. B Part B of the figure illustrates the mean post-intervention to pre-intervention adjusted DDD rate ratio, expressed as well as mean change in adjusted DDD rate relative to pre-intervention period (right Y axis) across three distinct groups: participating PCPs in KKC, non-participating PCPs in KKC and PCPs in BBC. Error bars in the graph represent 95% confidence interval. Y-axis is log-transformed. Additionally, the statistical significance of the comparison of mean rate ratios between the groups is denoted above the columns of each group pair with corresponding p value. AD – Academic Detailing; DDD—defined daily dose; KKC – Koprivnica-Križevci County; BBC – Bjelovar-Bilogora County; CI—confidence interval

Fig. 2

A Part A of the figure illustrates the mean adjusted defined daily dose (DDD) of antibiotics prescribed per day for the all five diagnosis put toogether (acute sinusitis, acute pharyngitis, acute tonsillitis, acute upper respiratory infections, and acute bronchitis). The data is presented before (pre-intervention period from 01st January 2018 to 31st March 2020) and after (post-intervention period from 1st May 2020 to 31st December 2022) the implementation of an academic detailing (AD) intervention across three distinct groups: participating primary care physicians (PCPs) in Koprivnica-Krizevci county (KKC), non-participating PCPs in KKC, and all (non-participating) PCPs in Bjelovar-Bilogora county (BBC). The error bars in the graph represent the 95% confidence interval (CI). Additionally, the statistical significance of the group-wise comparison of mean adjusted DDD/day pre- and post-intervention periods are denoted above the columns of each respective group with the corresponding p value. B Part B of the figure illustrates the mean post-intervention to pre-intervention adjusted DDD rate ratio, expressed as well as mean change in adjusted DDD rate relative to pre-intervention period (right Y axis) across three distinct groups: participating PCPs in KKC, non-participating PCPs in KKC and PCPs in BBC. Error bars in the graph represent 95% confidence interval. Y-axis is log-transformed. Additionally, the statistical significance of the comparison of mean rate ratios between the groups is denoted above the columns of each group pair with corresponding p value. AD – Academic Detailing; DDD—defined daily dose; KKC – Koprivnica-Križevci County; BBC – Bjelovar-Bilogora County; CI—confidence interval

Fig. 3

A Part A of the figure illustrates the mean adjusted defined daily dose (DDD) of groups antibiotics (penicillins-including β-lactamase inhibitors, penicillins, macrolides, cephalosporines and other antibiotics) prescribed per day for the all five diagnosis put together (acute sinusitis, acute pharyngitis, acute tonsillitis, acute upper respiratory infections, and acute bronchitis). The data is presented before (pre-intervention period from 01st January 2018 to 31st March 2020) and after (post-intervention period from 1st May 2020 to 31st December 2022) the implementation of an academic detailing (AD) intervention across three distinct groups: participating primary care physicians (PCPs) in Koprivnica-Krizevci county (KKC), non-participating PCPs in KKC, and all (non-participating) PCPs in Bjelovar-Bilogora county (BBC). The error bars in the graph represent the 95% confidence interval (CI). Additionally, the statistical significance of the group-wise comparison of mean adjusted DDD/day pre- and post-intervention periods are denoted above the columns of each respective group with the corresponding p value. B Part B of the figure illustrates the mean post-intervention to pre-intervention adjusted DDD rate ratio, expressed as well as mean change in adjusted DDD rate relative to pre-intervention period (right Y axis) across three distinct groups: participating PCPs in KKC, non-participating PCPs in KKC and PCPs in BBC. Error bars in the graph represent 95% confidence interval. Y-axis is log-transformed. Additionally, the statistical significance of the comparison of mean rate ratios between the groups is denoted above the columns of each group pair with corresponding p value. AD – Academic Detailing; DDD—defined daily dose; KKC – Koprivnica-Križevci County; BBC – Bjelovar-Bilogora County; CI—confidence interval

Fig. 4

A Part A of the figure illustrates the mean incidence of Clostridioides difficile infections (CDI) for hospital and primary care. The data is presented before (pre-intervention period from 01st January 2018 to 31st December 2019), during (intervention period from 1st January 2020 to 31st December 2020) and after (post-intervention period from 1st January 2021 to 31st December 2022) the implementation of an academic detailing (AD) intervention across two distinct groups: all (participating and non-participating) primary care physicians (PCPs) in Koprivnica-Krizevci county (KKC) and all (non-participating) PCPs in Bjelovar-Bilogora county (BBC). The error bars in the graph represent the 95% confidence interval (CI). B Part B of the figure illustrates the mean post-intervention to pre-intervention mean change in incidence (as well as incidence rate ratio (RR)) across two distinct groups: all PCPs in KKC and all PCPs in BBC. Error bars in the graph represent 95% confidence interval. Y-axis is log-transformed. Additionally, the statistical significance of the comparison of mean odds ratios between the groups is denoted above the columns of each group pair with corresponding p value. AD – Academic Detailing; KKC – Koprivnica-Križevci County; BBC – Bjelovar-Bilogora County; CI—confidence interval