The University of Southampton
University of Southampton Institutional Repository

Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study

Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study
Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study

BACKGROUND: Unnecessary prescribing of antibiotics in primary care is contributing to the emergence of antimicrobial drug resistance. OBJECTIVES: To develop and evaluate a multicomponent intervention for antimicrobial stewardship in primary care, and to evaluate the safety of reducing antibiotic prescribing for self-limiting respiratory infections (RTIs). INTERVENTIONS: A multicomponent intervention, developed as part of this study, including a webinar, monthly reports of general practice-specific data for antibiotic prescribing and decision support tools to inform appropriate antibiotic prescribing. DESIGN: A parallel-group, cluster randomised controlled trial. SETTING: The trial was conducted in 79 general practices in the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS: All registered patients were included. MAIN OUTCOME MEASURES: The primary outcome was the rate of antibiotic prescriptions for self-limiting RTIs over the 12-month intervention period. COHORT STUDY: A separate population-based cohort study was conducted in 610 CPRD general practices that were not exposed to the trial interventions. Data were analysed to evaluate safety outcomes for registered patients with 45.5 million person-years of follow-up from 2005 to 2014. RESULTS: There were 41 intervention trial arm practices (323,155 patient-years) and 38 control trial arm practices (259,520 patient-years). There were 98.7 antibiotic prescriptions for RTIs per 1000 patient-years in the intervention trial arm (31,907 antibiotic prescriptions) and 107.6 per 1000 patient-years in the control arm (27,923 antibiotic prescriptions) [adjusted antibiotic-prescribing rate ratio (RR) 0.88, 95% confidence interval (CI) 0.78 to 0.99; p = 0.040]. There was no evidence of effect in children aged < 15 years (RR 0.96, 95% CI 0.82 to 1.12) or adults aged ≥ 85 years (RR 0.97, 95% CI 0.79 to 1.18). Antibiotic prescribing was reduced in adults aged between 15 and 84 years (RR 0.84, 95% CI 0.75 to 0.95), that is, one antibiotic prescription was avoided for every 62 patients (95% CI 40 to 200 patients) aged 15-84 years per year. Analysis of trial data for 12 safety outcomes, including pneumonia and peritonsillar abscess, showed no evidence that these outcomes might be increased as a result of the intervention. The analysis of data from non-trial practices showed that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then 1.1 (95% CI 0.6 to 1.5) more cases of pneumonia per year and 0.9 (95% CI 0.5 to 1.3) more cases of peritonsillar abscesses per decade may be observed. There was no evidence that mastoiditis, empyema, meningitis, intracranial abscess or Lemierre syndrome were more frequent at low-prescribing practices. LIMITATIONS: The research was based on electronic health records that may not always provide complete data. The number of practices included in the trial was smaller than initially intended. CONCLUSIONS: This study found evidence that, overall, general practice antibiotic prescribing for RTIs was reduced by this electronically delivered intervention. Antibiotic prescribing rates were reduced for adults aged 15-84 years, but not for children or the senior elderly. FUTURE WORK: Strategies for antimicrobial stewardship should employ stratified interventions that are tailored to specific age groups. Further research into the safety of reduced antibiotic prescribing is also needed. TRIAL REGISTRATION: Current Controlled Trials ISRCTN95232781. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 11. See the NIHR Journals Library website for further project information.

ANTIBIOTICS, BACTERIAL MENINGITIS, EMPYEMA, INTRACRANIAL ABSCESS, MASTOIDITIS, PERITONSILLAR ABSCESS, PNEUMONIA, PRIMARY CARE, RESPIRATORY TRACT INFECTIONS
1366-5278
1-70
Gulliford, Martin C.
5c557aa2-db12-43a2-8778-eac74cf42138
Juszczyk, Dorota
c9c7c039-5bae-4c5f-8df7-75f30e7a9c53
Prevost, A. Toby
5fd7066c-e170-46f6-8d3e-501532dc7810
Soames, Jamie
7e6dccf8-a923-4161-a2b6-b1fdd2c7e85c
McDermott, Lisa
738bfcbd-aa46-4d87-b646-6658bb0aa7bc
Sultana, Kirin
1d88fbae-5f1a-4fbd-82d8-3973262ea671
Wright, Mark
2e6debac-0253-487b-b36c-dba3d475f8b7
Fox, Robin
df22d09d-ede6-42c8-99d7-563a14173c0c
Hay, Alastair D.
981450c6-76fc-44ea-b4b8-1063059d2e80
Little, Paul
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
Moore, Michael
1be81dad-7120-45f0-bbed-f3b0cc0cfe99
Yardley, Lucy
64be42c4-511d-484d-abaa-f8813452a22e
Ashworth, Mark
51302b16-d1e8-4221-a192-04aebdd16f77
Charlton, Judith
27682a6d-c126-45fb-a8a1-dbde57ccb4e9
Gulliford, Martin C.
5c557aa2-db12-43a2-8778-eac74cf42138
Juszczyk, Dorota
c9c7c039-5bae-4c5f-8df7-75f30e7a9c53
Prevost, A. Toby
5fd7066c-e170-46f6-8d3e-501532dc7810
Soames, Jamie
7e6dccf8-a923-4161-a2b6-b1fdd2c7e85c
McDermott, Lisa
738bfcbd-aa46-4d87-b646-6658bb0aa7bc
Sultana, Kirin
1d88fbae-5f1a-4fbd-82d8-3973262ea671
Wright, Mark
2e6debac-0253-487b-b36c-dba3d475f8b7
Fox, Robin
df22d09d-ede6-42c8-99d7-563a14173c0c
Hay, Alastair D.
981450c6-76fc-44ea-b4b8-1063059d2e80
Little, Paul
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
Moore, Michael
1be81dad-7120-45f0-bbed-f3b0cc0cfe99
Yardley, Lucy
64be42c4-511d-484d-abaa-f8813452a22e
Ashworth, Mark
51302b16-d1e8-4221-a192-04aebdd16f77
Charlton, Judith
27682a6d-c126-45fb-a8a1-dbde57ccb4e9

Gulliford, Martin C., Juszczyk, Dorota, Prevost, A. Toby, Soames, Jamie, McDermott, Lisa, Sultana, Kirin, Wright, Mark, Fox, Robin, Hay, Alastair D., Little, Paul, Moore, Michael, Yardley, Lucy, Ashworth, Mark and Charlton, Judith (2019) Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study. Health Technology Assessment, 23 (11), 1-70. (doi:10.3310/hta23110).

Record type: Article

Abstract

BACKGROUND: Unnecessary prescribing of antibiotics in primary care is contributing to the emergence of antimicrobial drug resistance. OBJECTIVES: To develop and evaluate a multicomponent intervention for antimicrobial stewardship in primary care, and to evaluate the safety of reducing antibiotic prescribing for self-limiting respiratory infections (RTIs). INTERVENTIONS: A multicomponent intervention, developed as part of this study, including a webinar, monthly reports of general practice-specific data for antibiotic prescribing and decision support tools to inform appropriate antibiotic prescribing. DESIGN: A parallel-group, cluster randomised controlled trial. SETTING: The trial was conducted in 79 general practices in the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS: All registered patients were included. MAIN OUTCOME MEASURES: The primary outcome was the rate of antibiotic prescriptions for self-limiting RTIs over the 12-month intervention period. COHORT STUDY: A separate population-based cohort study was conducted in 610 CPRD general practices that were not exposed to the trial interventions. Data were analysed to evaluate safety outcomes for registered patients with 45.5 million person-years of follow-up from 2005 to 2014. RESULTS: There were 41 intervention trial arm practices (323,155 patient-years) and 38 control trial arm practices (259,520 patient-years). There were 98.7 antibiotic prescriptions for RTIs per 1000 patient-years in the intervention trial arm (31,907 antibiotic prescriptions) and 107.6 per 1000 patient-years in the control arm (27,923 antibiotic prescriptions) [adjusted antibiotic-prescribing rate ratio (RR) 0.88, 95% confidence interval (CI) 0.78 to 0.99; p = 0.040]. There was no evidence of effect in children aged < 15 years (RR 0.96, 95% CI 0.82 to 1.12) or adults aged ≥ 85 years (RR 0.97, 95% CI 0.79 to 1.18). Antibiotic prescribing was reduced in adults aged between 15 and 84 years (RR 0.84, 95% CI 0.75 to 0.95), that is, one antibiotic prescription was avoided for every 62 patients (95% CI 40 to 200 patients) aged 15-84 years per year. Analysis of trial data for 12 safety outcomes, including pneumonia and peritonsillar abscess, showed no evidence that these outcomes might be increased as a result of the intervention. The analysis of data from non-trial practices showed that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then 1.1 (95% CI 0.6 to 1.5) more cases of pneumonia per year and 0.9 (95% CI 0.5 to 1.3) more cases of peritonsillar abscesses per decade may be observed. There was no evidence that mastoiditis, empyema, meningitis, intracranial abscess or Lemierre syndrome were more frequent at low-prescribing practices. LIMITATIONS: The research was based on electronic health records that may not always provide complete data. The number of practices included in the trial was smaller than initially intended. CONCLUSIONS: This study found evidence that, overall, general practice antibiotic prescribing for RTIs was reduced by this electronically delivered intervention. Antibiotic prescribing rates were reduced for adults aged 15-84 years, but not for children or the senior elderly. FUTURE WORK: Strategies for antimicrobial stewardship should employ stratified interventions that are tailored to specific age groups. Further research into the safety of reduced antibiotic prescribing is also needed. TRIAL REGISTRATION: Current Controlled Trials ISRCTN95232781. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 11. See the NIHR Journals Library website for further project information.

Full text not available from this repository.

More information

Published date: March 2019
Keywords: ANTIBIOTICS, BACTERIAL MENINGITIS, EMPYEMA, INTRACRANIAL ABSCESS, MASTOIDITIS, PERITONSILLAR ABSCESS, PNEUMONIA, PRIMARY CARE, RESPIRATORY TRACT INFECTIONS

Identifiers

Local EPrints ID: 430063
URI: https://eprints.soton.ac.uk/id/eprint/430063
ISSN: 1366-5278
PURE UUID: 92912a59-4597-4953-98d2-dc7ab9967ef0
ORCID for Michael Moore: ORCID iD orcid.org/0000-0002-5127-4509
ORCID for Lucy Yardley: ORCID iD orcid.org/0000-0002-3853-883X

Catalogue record

Date deposited: 11 Apr 2019 16:30
Last modified: 10 Sep 2019 00:50

Export record

Altmetrics

Contributors

Author: Martin C. Gulliford
Author: Dorota Juszczyk
Author: A. Toby Prevost
Author: Jamie Soames
Author: Lisa McDermott
Author: Kirin Sultana
Author: Mark Wright
Author: Robin Fox
Author: Alastair D. Hay
Author: Paul Little
Author: Michael Moore ORCID iD
Author: Lucy Yardley ORCID iD
Author: Mark Ashworth
Author: Judith Charlton

University divisions

Download statistics

Downloads from ePrints over the past year. Other digital versions may also be available to download e.g. from the publisher's website.

View more statistics

Atom RSS 1.0 RSS 2.0

Contact ePrints Soton: eprints@soton.ac.uk

ePrints Soton supports OAI 2.0 with a base URL of https://eprints.soton.ac.uk/cgi/oai2

This repository has been built using EPrints software, developed at the University of Southampton, but available to everyone to use.

We use cookies to ensure that we give you the best experience on our website. If you continue without changing your settings, we will assume that you are happy to receive cookies on the University of Southampton website.

×