Appendix C.

Summary of the Impact of Ambulatory Antimicrobial Stewardship Interventions*

ReferenceProcess OutcomePatient OutcomeProvider OutcomeClinic OutcomeSystem Outcome
Litvin et al20• Choice of prescribing antibiotics
Persell et al21• Prescribing antibiotics• Prescribed antibiotics in 24.7% of inappropriate ARI diagnoses prior to and only 5.2% after the study
• Suggested alternative intervention decreased antibiotic prescribing
• Suggested alternatives and peer comparisons decreased antibiotic prescribing for all ARI diagnoses combined
Hux et al22• Most providers were satisfied with intervention
• More first line antibiotics used
• Median prescription cost rose in control group
Hallsworth et al23• Antibiotic prescription/1,000 people decreased
Strykowski et al24• GPs in full intervention reduced antibiotic overprescribing (OR, 0.35; 95% CI, 0.18 to 0.68)
• Underprescribing was not significantly increased (OR, 0.25; 95%CI, 0.06 to 1.0; P = .075)
Foxman et al25• 85% more antibiotics prescribed among those without copays than among those with copays
Long et al26• Median duration of antibiotic: 5 days in intervention versus 7 days in control group
• Prescription of antibiotics 84.4% in intervention versus 97.5% in control group
Arakaki et al27• Diagnosis of cellulitis made in 2/20 in intervention group and 3/9 in control group• Antibiotic use in 2/20 patients in intervention versus all in control group
• All improved 1 week later
Taylor et al28• Number of ARI visits did not change
• Number of diagnoses and antibiotic prescriptions for otitis media and sinusitis did not change
• Antibiotic prescriptions per patient did not change
Torres et al29• Five patients in each group had unfavorable outcomes• Antibiotic use decreased in clinical prediction group (48.6% versus 86.6%, P < .001)
Le Corvoisier et al30• Proportion of prescriptions containing an antibiotic decreased in intervention (15.2% to 12.3%; P < .001) but not control (15.3% to 16.4%; between group difference 3.93%)
• Maintained improvement for 30 months after intervention terminated
• More symptomatic treatment prescribed in treatment than control (7.8% versus 3.9%)
Meeker et al31• Antibiotic prescribing for nonindicated ARIs decreased in intervention (42.8% to 33.7%) but not control (43.5% to 52.7%)
• Posted commitment letter decreased antibiotic prescribing for nonindicated diagnoses by 19.7%
• No change in appropriate antibiotic prescriptions
• No diagnostic coding shift
Brittain-Long et al32• Rapid test result group prescribed fewer antibiotics within 48 hours of visit (4.5% versus 12.3%)
• No difference in symptoms at follow-up
• No significant adverse events
Christakis et al33• Proportion of prescriptions for otitis media <10 days decreased 34% in intervention group
• Less likely to prescribe antibiotics in intervention
Dahler-Eriksen et al35• Antibiotics started earlier in patients with lower CRP concentrations
• No reduction in antibiotics
• Use of ESRs decreased by 8% in intervention
• Blood samples sent to hospital lab decreased by 6%
• Proportion of study patients needing a follow-up telephone call reduced from 63% to 53%
De la Poza Abad et al36• Symptom duration increased only for the no-prescription group
• No difference in symptom severity
• Antibiotic use less in no-prescription and delayed strategies
• Patient satisfaction similar across all groups
• Patient belief in antibiotic effectiveness decreased in no-prescription and delayed strategies
Hemkens et al37• Only 11% of physicians in the intervention group logged onto the online audit and feedback tool• Overall antibiotic prescription in defined daily doses/100 clinic visits did not decrease in the first or second year (0.81%, P = .64; −1.73%, P = .32; respectively)
• Antibiotic prescribing decreased 8.61% among 6 to 18-year-old children in first year only (P = .01)
• Antibiotic prescribing declined 4.59% among adults aged 19 to 65 in second year only (P < .01)
Samore et al38• Macrolides decreased in CDSS but not in community intervention alone
• Greater decrease in antibiotic prescribing in CDSS than in community intervention alone
Gerber et al39• Combination of 2 practices decreased overall and broad-spectrum antibiotic prescribing
Gerber et al40• Antibiotic prescribing increased after intervention ended (intervention, 16.7% to 27.9%; controls, 25.4% to 30.2%; P = .02)
Gonzales et al41• Educational intervention did not further decrease ARI antibiotic prescription
Jenkins et al42• Antibiotic prescriptions decreased 42.7% to 37.9% versus 39.8% to 38.7%
• Decreased broad-spectrum antibiotic use
Finkelstein et al43• Ages 3 months to 3 years: intervention decreased 18.6% versus 11.5% in controls (16% adjusted effect)
• Age 3 to 5 years: intervention decreased 15% versus 9.8% in controls (12% adjusted effect)
Meeker44• Control practices: antibiotic prescription decreased from 24.1% to 13.1%
• Suggested alternatives: prescriptions decreased from 22.1% to 6.1% (insignificant)
• Accountable justification: prescriptions decreased from 23.2% to 5.2%
• Peer comparison: prescriptions decreased from 19.9% to 3.7%
• No interactions seen
Yang et al45• Reporting at individual and institutional level• Public reporting resulted in 9% decline in antibiotics
Schnoor et al46• Decrease in CAP-related mortality higher in intervention (2.9% versus 0.5%)
• No change in patient adherence to duration of treatment
• Increased proportion of visits adhering to antibiotic guidelines (5.6%)
Finkelstein et al47• Downward trend in prescribing even without intervention
• Change in antibiotics dispensed per person-year: no decrease in those <2 years, but 4.6% decrease in 2 to 3 years and 6.7% decrease in 4 to 5 years
Huang et al48• More parents in intervention communities correctly answered survey questions
Vervloet et al49• Number of ARI antibiotic prescriptions decreased overall, but intervention group improved more
Linder et al50• 6% of ARI visits in the CDS group used the CDS• Antibiotic prescribing rate for ARIs 39% in intervention versus 43% in control clinics (OR, 0.8; 95% CI, 0.6 to 1.2)
• For antibiotic-appropriate ARIs, no difference antibiotic prescribing in intervention and control clinics (54% versus 59%)
• For nonantibiotic appropriate diagnoses, no difference intervention and control clinics (32% versus 34%)
• When CDSS used, associated with a lower antibiotic prescribing rate for acute bronchitis (OR, 0.5; 95% CI, 0.3 to 0.8)
Linder et al51• Only 28% of intervention clinicians logged into the quality dashboard• No difference in antibiotic prescribing for ARI visits overall (47% versus 47%, P = .87), antibiotic-appropriate ARI visits (65% versus 64%, P = .68), or nonantibiotic-appropriate ARI visits (38% versus 40%, P = .70)
• Those who used the dashboard had a lower ARI prescribing rate (42% versus 50%, P = .02)
Cals et al52• Antibiotic prescribing at index visit: 31% in CRP and 53% without CRP; 27% in education and 54% in no training
• Antibiotic prescribing during 28-day follow-up: no difference
• Total antibiotic prescribing: 45% versus 58% with and without CRP and 38% versus 63% in communication skills training
Cals et al53• Long-term follow-up over next 2 to 3 years: no difference number of LRTI visits• CRP not used over time: only in 3.7% of visits 2 to 3 years later• Communication training led to a long-term decrease of 10.4% in visits resulting in antibiotic prescription
Mainous et al54• Use of CDSS tool
• Help with diagnosis
• Decide about antibiotics
• How often CDSS template used
• Decreased overall prescribing of broad-spectrum antibiotics in adults and children (16.6% to 1.1% and 19.7% to 0.9%, respectively) and antibiotics overall among adults• How often CDSS template used
• Inappropriate prescribing
• Diagnostic shift
Slekovec et al55• Quinolone prescriptions decreased by 9%, but nitrofurantoin and fosfomycin increased by 36.8% and 28.5% respectively
Gonzales et al56• No adverse impact on emergency department visits or ARI complications• Fewer pediatric clinic visits• Cost savings
• 3.8% decrease in antibiotic prescriptions/1000 persons
• 8.8% decrease in antibiotic dispenses/1000 managed care members
Hurlimann et al57• Increased percentage of prescriptions of penicillins for ARIs treated with antibiotics (49% to 57%)
• Did not decrease the percentage of COPD exacerbations treated with fluoroquinolones
• Did not decrease the proportion of sinusitis and other upper ARIs treated with antibiotics
Vinnard et al58• Nonindicated antibiotic prescriptions decreased from 43% to 33% in academic detailing group
Gonzales et al59• Full intervention decreased antibiotic prescription for acute bronchitis (74% to 48%) but not control (78% to 76%) or limited intervention (82% to 77%)• Diagnoses of acute bronchitis did not change
Gonzales et al60• Antibiotic prescribed to 64% of respondents at intervention and control clinics
• Patient satisfaction did not differ: 69% very good or excellent satisfaction in intervention clinic, 63% in control clinic
Formoso et al61• Defined daily doses of antibiotics/1,000 person-days decreased 4.3% in intervention area
• Broad-spectrum antibiotics decreased more
• Intervention did not affect knowledge and attitudes about antibiotic resistance
Yardley et al62• Communication patient and clinician
• Decision to provide antibiotic
• Belief in harm or need for antibiotics
• Attitudes towards antibiotics
• CRP: patient feels less enabled and less satisfied
• Importance of reducing antibiotic use
• Perceptions of damage to patient/clinician relationship
• Those who did CRP testing showed trend of lost confidence in ability to reduce antibiotic prescribing
• CRP testing means less antibiotics
Szymczak et al63• Gaming of audit and feedback• Belief in audit and feedback reports
Mustafa et al64• Learn patient expectations• Decide on antibiotic• Patient/provider relationship
• Education
• Set expectations with next ARI
• Avoid confrontation
• Patient/provider relationship
• Dissatisfaction
• Be a good physician
• Pride in practice• Antibiotic resistance
Grondal et al65• Choice to do rapid Streptococcus test
• Choice to do CRP
• Antibiotics prescribed
Munoz-Plaza et al66• Poor satisfaction• Unwarranted prescribing practices for sinusitis
• Poor patient satisfaction score
Tonkin-Crine et al67• Use of guidelines among GPs• Engage GPs in interventions
Wood et al68• GPs perceive antibiotic resistance as due to secondary care, pharmacists, dentists, and even other countries
Mauffrey et al70• Interventions should not impact clinic flow
Ronnerstrand et al71• Patient trust in others
Dempsey et al72• Perception of patient requests
Huddy et al69• Quality checks of POC CRP testing• Patients like the test• Increase job satisfaction• Too many visits
Rowbotham et al73• Clinician confidence
Kuzujanakis et al74• Prescribed antibiotic
• Education on antibiotics
Ackerman et al75• Preferred an exam room poster with diagnostic algorithm• Patient expectations seen as impacting prescribing• Compared with prior surveys, clinicians demonstrated greater awareness of antibiotic resistance and impact of their prescribing decisions
Murphy et al76• Reminder of danger of antibiotic resistance
Anthierens et al77• Communication with patients• Patient satisfaction• Education about antibiotic resistance• Fewer visits, decreased income
  • ARI, acute respiratory infection; CDSS, clinical decision support system; OR, odds ratio; CI, confidence interval; CAP, community-acquired pneumonia; CRP, C-reactive protein; LRTI, lower respiratory tract infection; COPD, chronic obstructive pulmonary disease; ESR, erythrocyte sedimentation rate; POC, point of care; GP, general practitioner.

  • * As studied in rigorously designed quantitative and qualitative studies describing the context around antibiotic prescribing decisions and antibiotic stewardship interventions, through November 7, 2016 on outcomes, including process outcomes and outcomes to the patient, provider, clinic, and health system.