Background Antibiotic use and concomitant resistance are increasing. Literature reviews do not unambiguously indicate which interventions are most effective in improving antibiotic prescribing practice. Aim To assess the effectiveness of physician-targeted interventions aiming to improve antibiotic prescribing for respiratory tract infections (RTIs) in primary care, and to identify intervention features mostly contributing to intervention success. Design and setting Analysis of a set of physician-targeted interventions in primary care. Method A literature search (1990–2009) for studies describing the effectiveness of interventions aiming to optimise antibiotic prescription for RTIs by primary care physicians. Intervention features were extracted and effectiveness sizes were calculated. Association between intervention features and intervention success was analysed in multivariate regression analysis. Results This study included 58 studies, describing 87 interventions of which 60% significantly improved antibiotic prescribing; interventions aiming to decrease overall antibiotic prescription were more frequently effective than interventions aiming to increase first choice prescription. On average, antibiotic prescription was reduced by 11.6%, and first choice prescription increased by 9.6%. Multiple interventions containing at least ‘educational material for the physician’ were most often effective. No significant added value was found for interventions containing patient-directed elements. Communication skills training and near-patient testing sorted the largest intervention effects. Conclusion This review emphasises the importance of physician education in optimising antibiotic use. Further research should focus on how to provide physicians with the relevant knowledge and tools, and when to supplement education with additional intervention elements. Feasibility should be included in this process.

Countries generally present their overall use of antibiotics as an indicator of antibiotic prescribing quality. Additional insight is urgently needed for targeted improvement recommendations: first, data on specific clinical indications for which antibiotics are used, and second, on distinguishing whether changes in patient consultation or changes in physician prescribing drive changing antibiotic use for particular indications. The aim of this study was to describe the antibiotic management of infectious diseases in the clinical context, by analysing prescribing by physicians and patient consultation incidences per indication over time. A database with all contact data for infectious diseases from 45 primary care practices in the Netherlands (2007–10) was used. Consultation incidences, prescribing rates and choice of antibiotic were analysed per International Classification of Primary Care (ICPC) chapter and relevant ICPC codes. Antibiotics were prescribed in ∼25% of infectious disease episodes, mainly respiratory infections, urinary infections and ear and skin infections. Overall, this resulted in 300 prescribed courses of antibiotics per 1000 patient–years. Given a stable prescription rate, a 19% increase in the number of consultations explained the increased antibiotic prescribing for urinary tract infections. Given a stable consultation incidence, an 8% reduction in prescribing rate explained the decreased antibiotic prescribing for respiratory tract infections. Macrolides were predominantly prescribed for respiratory disease (∼66%), amoxicillin/clavulanate for respiratory disease (∼42%) and urinary illness (∼25%), and fluoroquinolones for urinary and genital indications. Insight into the reasons for the decreased prescribing for respiratory tract infections and the increased prescribing for urinary tract infections was provided by a detailed analysis of incidences and prescribing rates. For respiratory disease, the second- and third-choice antibiotics were overused. Complete data on infectious disease management, with respect to patient and physician behaviour, are crucial for understanding changes in antibiotic use, and in defining strategies to reduce inappropriate antibiotic use.

Since the start of out-of-hours (OOH) primary care clinics, the number of patient consultations has been increasing. Triage plays an important role in patient selection for a consultation, and in providing reassurance and self-management advice. We aimed to investigate whether the smartphone application “Should I see a doctor?” (in Dutch:”moet ik naar de dokter?”) could guide patients in appropriate consultation at OOH clinics by focusing on four topics: 1) app usage, 2) user satisfaction, 3) whether the app provides the correct advice, and 4) whether users intend to follow the advice. A prospective, cross-sectional study amongst app users in a routine primary care setting. The app is a self-triage tool for acute primary care. A built-in questionnaire asked users about the app’s clarity, their satisfaction and whether they intended to follow the app’s advice (n = 4456). A convenience sample of users was phoned by a triage nurse (reference standard) to evaluate whether the app’s advice corresponded with the outcome of the triage call (n = 126). Suggestions of phoned participants were listed. The app was used by patients of all ages, also by parents for their children, and mostly for abdominal pain, skin disorders and cough. 58% of users received the advice to contact the clinic, 34% a self-care advice and 8% to wait-and-see. 65% of users intended to follow the app’s advice. The app was rated as ‘neutral’ to ‘very clear’ by 87%, and 89% were ‘neutral’ to ‘very satisfied’. In 81% of participants the app’s advice corresponded to the triage call outcome, with sensitivity, specificity, positive- and negative predictive values of 84%, 74%, 88% and 67%, respectively. The app “Should I see a doctor?” could be a valuable tool to guide patients in contacting the OOH primary care clinic for acute care. To further improve the app’s safety and efficiency, triaging multiple symptoms should be facilitated, and more information should be provided to patients receiving a wait-and-see advice.

To reduce the spread of antibiotic resistance, there is a pressing need for worldwide implementation of effective interventions to promote more prudent prescribing of antibiotics for acute LRTI. This study is a process analysis of the GRACE/INTRO trial of a multifactorial intervention that reduced antibiotic prescribing for acute LRTI in six European countries. The aim was to understand how the interventions were implemented and to examine effects of the interventions on general practitioners’ (GPs’) and patients’ attitudes. GPs were cluster randomised to one of three intervention groups or a control group. The intervention groups received web-based training in either use of the C-reactive protein (CRP) test, communication skills and use of a patient booklet, or training in both. GP attitudes were measured before and after the intervention using constructs from the Theory of Planned Behaviour and a Website Satisfaction Questionnaire. Effects of the interventions on patients were assessed by a post-intervention questionnaire assessing patient enablement, satisfaction with the consultation, and beliefs about the risks and need for antibiotics. GPs in all countries and intervention groups had very positive perceptions of the intervention and the web-based training, and felt that taking part had helped them to reduce prescribing. All GPs perceived reducing prescribing as more important and less risky following the intervention, and GPs in the communication groups reported increased confidence to reduce prescribing. Patients in the communication groups who received the booklet reported the highest levels of enablement and satisfaction and had greater awareness that antibiotics could be unnecessary and harmful. Our findings suggest that the interventions should be broadly acceptable to both GPs and patients, as well as feasible to roll out more widely across Europe. There are also some indications that they could help to engender changes in GP and patient attitudes that will be helpful in the longer-term, such as increased awareness of the potential disadvantages of antibiotics and increased confidence to manage LRTI without them. Given the positive effects of the booklet on patient beliefs and attitudes, it seems logical to extend the use of the patient booklet to all patients.

Antibiotic overprescribing is a significant problem. Multifaceted interventions improved antibiotic prescribing quality; their implementation and sustainability, however, have proved difficult. We analysed the effectiveness of an intervention embedded in the quality cycle of primary care practice accreditation on quantity and quality of antibiotic prescribing for respiratory tract and ear infections (RTIs). This was a pragmatic, cluster-randomized intervention trial in 88 Dutch primary care practices. The intervention (physician education and audit/feedback on antibiotic prescribing quantity and quality) was integrated in practice accreditation by defining an improvement plan with respect to antibiotic prescribing for RTIs. Numbers and types of dispensed antibiotics were analysed from 1 year prior to the intervention to 2 years after the intervention (pharmacy data). Overprescribing, underprescribing and non-first-choice prescribing for RTIs were analysed at baseline and 1 year later (self-registration). There were significant differences between intervention and control practices in the changes in dispensed antibiotics/1000 registered patients (first year: −7.6% versus −0.4%, P = 0.002; second year: −4.3% versus +2%, P = 0.015), which was more pronounced for macrolides and amoxicillin/clavulanate (first year: −12.7% versus +2.9%, P = 0.001; second year: −7.8% versus +6.7%, P = 0.005). Overprescribing for RTIs decreased from 44% of prescriptions to 28% (P < 0.001). Most general practitioners (GPs) envisaged practice accreditation as a tool for guideline implementation. GP education and an audited improvement plan around antibiotics for RTIs as part of primary care practice accreditation sustainably improved antibiotic prescribing. Tools should be sought to further integrate and facilitate education and audit/feedback in practice accreditation.

In 2020, the COVID-19 pandemic brought dramatic changes in the delivery of primary health care across the world, presumably changing the number of consultations for infectious diseases and antibiotic use. We aimed to assess the impact of the pandemic on infections and antibiotic prescribing in Dutch primary care. All patients included in the routine health care database of the Julius General Practitioners’ Network were followed from March through May 2019 (n = 389,708) and March through May 2020 (n = 405,688). We extracted data on consultations for respiratory/ear, urinary tract, gastrointestinal and skin infections using the International Classification of Primary Care (ICPC) codes. These consultations were combined in disease episodes and linked to antibiotic prescriptions. The numbers of infectious disease episodes (total and those treated with antibiotics), complications, and antibiotic prescription rates (i.e., proportion of episodes treated with antibiotics) were calculated and compared between the study periods in 2019 and 2020. Fewer episodes were observed during the pandemic months than in the same months in 2019 for both the four infectious disease entities and complications such as pneumonia, mastoiditis and pyelonephritis. The largest decline was seen for gastrointestinal infections (relative risk (RR), 0.54; confidence interval (CI), 0.51 to 0.58) and skin infections (RR, 0.71; CI, 0.67 to 0.75). The number of episodes treated with antibiotics declined as well, with the largest decrease seen for respiratory/ear infections (RR, 0.54; CI, 0.52 to 0.58). The antibiotic prescription rate for respiratory/ear infections declined from 21% to 13% (difference −8.0% (CI, −8.8 to −7.2)), yet the prescription rates for other infectious disease entities remained similar or increased slightly. The decreases in primary care infectious disease episodes and antibiotic use were most pronounced in weeks 15–19, mid-COVID-19 wave, after an initial peak in respiratory/ear infection presentation in week 11, the first week of lock-down. In conclusion, our findings indicate that the COVID-19 pandemic has had profound effects on the presentation of infectious disease episodes and antibiotic use in primary care in the Netherlands. Consequently, the number of infectious disease episodes treated with antibiotics decreased. We found no evidence of an increase in complications.