Rational antibiotic prescribing

The authors of this paper in the British Medical Journal evaluated the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care.

They used a randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation. The study was carried out in 68 general practices with about 480 000 patients in Wales, UK. Thirty-four practices were randomised to receive the educational programme and 34 practices to be controls. A total of 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed.

The interventions followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice-based seminar reflecting on the practices’ own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care.

The main outcome measures were the total numbers of oral antibiotic items dispensed for all causes per 1 000 practice patients in the year after the intervention, adjusted for the previous year’s dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes, and costs.

The rate of oral antibiotic dispensing (items per 1 000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% CI 0.6 - 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (p=0.02). Reductions were found for all classes of antibiotics other than penicillinase-resistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4 - 13.7%) and macrolides (7.7%, 1.1 - 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within 7 days of an index consultation. The mean cost of the programme was £2 923 (€3 491, $4 572) per practice (SD £1 187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (−0.4 - 11.4%), equivalent to a reduction of about £830 a year for an average intervention practice.

The conclusion was that the STAR educational programme led to reductions in all-cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations, or costs.

Butler CC et al. BMJ 2012;344:d8173.