High-volume prescribing of antibiotics in primary care is a major driver of antibiotic resistance. Education of physicians and patients can lower prescribing levels, but it frequently relies on highly trained staff. We assessed whether internet-based training methods could alter prescribing practices in multiple health-care systems. After a baseline audit in October to December, 2010, primary-care practices in six European countries were cluster randomised to usual care, training in the use of a C-reactive protein (CRP) test at point of care, in enhanced communication skills, or in both CRP and enhanced communication. Patients were recruited from February to May, 2011. This trial is registered, number ISRCTN99871214. The baseline audit, done in 259 practices, provided data for 6771 patients with lower-respiratory-tract infections (3742 [55·3%]) and upper-respiratory-tract infections (1416 [20·9%]), of whom 5355 (79·1%) were prescribed antibiotics. After randomisation, 246 practices were included and 4264 patients were recruited. The antibiotic prescribing rate was lower with CRP training than without (33% vs 48%, adjusted risk ratio 0·54, 95% CI 0·42-0·69) and with enhanced-communication training than without (36% vs 45%, 0·69, 0·54-0·87). The combined intervention was associated with the greatest reduction in prescribing rate (CRP risk ratio 0·53, 95% CI 0·36-0·74, p<0·0001; enhanced communication 0·68, 0·50-0·89, p=0·003; combined 0·38, 0·25-0·55, p<0·0001). Internet training achieved important reductions in antibiotic prescribing for respiratory-tract infections across language and cultural boundaries. European Commission Framework Programme 6, National Institute for Health Research, Research Foundation Flanders.

Numerous interventions have been developed to promote prudent antibiotic use for acute respiratory tract infections (ARTIs). While reviews have assessed which interventions may be most effective, none has examined why some interventions may be more effective than others. Knowing what general practitioners (GPs) feel is acceptable and feasible to implement may help to answer this question. A systematic review was undertaken of 12 studies of GPs' views and experiences of antibiotic prescribing and/or interventions promoting the prudent use of antibiotics. A meta-ethnographic approach was followed to synthesize the findings. Thirteen themes were identified from the synthesis. The first discussed GPs' satisfaction with their prescribing decisions. Seven themes highlighted factors that influence GPs' prescribing decisions; these included perceptions of external pressure to reduce prescribing, uncertainty about ARTI management and previous experience of ARTI management. Five themes highlighted the benefits of interventions that had helped GPs to prescribe more prudently in practice. The last two sets of themes were linked to indicate that interventions may only be beneficial for GPs when they address one or more of the factors that influence their prescribing decisions. The findings suggest that interventions should incorporate five aspects to promote prudent use whilst remaining attractive to GPs and feasible in practice. In order to maximize acceptability, interventions should: allow GPs to reflect on their own prescribing; help decrease uncertainty about appropriate ARTI management; educate GPs about appropriate prescribing; facilitate more patient-centred care; and be beneficial to implement in practice.

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.

Background In 2007, ESAC (http://www.esac.ua.ac.be) published a set of 12 valid drug-specific quality indicators for outpatient antibiotic use in Europe. In this study, the authors aimed to develop evidence-based disease-specific quality indicators for outpatient antibiotic prescribing in Europe. Methods Two meetings were convened to produce a list of disease-specific quality indicators for outpatient antibiotic prescribing which conform to internationally agreed recommendations, building on a similar development of drug-specific quality indicators, and in collaboration with CHAMP and HAPPY AUDIT. 62 experts were asked to complete two scoring rounds of the proposed indicators on seven dimensions: their relevance to (1) reducing antimicrobial resistance, (2) patient health benefit, (3) cost-effectiveness, (4) policy makers, (5) individual prescribers, (6) their evidence base and (7) their range of acceptable use, using a scale ranging from 1 (=completely disagree) to 9 (=completely agree). Scores were judged according to the UCLA-RAND appropriateness method. Results For the six main indications for antibiotic prescribing (acute otitis media, acute upper-respiratory infection, acute/chronic sinusitis, acute tonsillitis, acute bronchitis/bronchiolitis, cystitis/other urinary infection) and for pneumonia, three quality indicators were proposed, the percentage prescribed (a) antibiotics; (b) recommended antibiotics; (c) quinolones. This set was scored by 40 experts from 25 countries. After one scoring round, all indicators were already rated as relevant on all dimensions, except one. Conclusion All proposed disease-specific quality indicators for outpatient antibiotic prescribing have face validity and are potentially applicable. They could be used to better describe antibiotic use and assess the quality of antibiotic prescribing patterns in ambulatory care.

Mixed methods are commonly used in health services research; however, data are not often integrated to explore complementarity of findings. A triangulation protocol is one approach to integrating such data. A retrospective triangulation protocol was carried out on mixed methods data collected as part of a process evaluation of a trial. The multi-country randomised controlled trial found that a web-based training in communication skills (including use of a patient booklet) and the use of a C-reactive protein (CRP) point-of-care test decreased antibiotic prescribing by general practitioners (GPs) for acute cough. The process evaluation investigated GPs’ and patients’ experiences of taking part in the trial. Three analysts independently compared findings across four data sets: qualitative data collected view semi-structured interviews with (1) 62 patients and (2) 66 GPs and quantitative data collected via questionnaires with (3) 2886 patients and (4) 346 GPs. Pairwise comparisons were made between data sets and were categorised as agreement, partial agreement, dissonance or silence. Three instances of dissonance occurred in 39 independent findings. GPs and patients reported different views on the use of a CRP test. GPs felt that the test was useful in convincing patients to accept a no-antibiotic decision, but patient data suggested that this was unnecessary if a full explanation was given. Whilst qualitative data indicated all patients were generally satisfied with their consultation, quantitative data indicated highest levels of satisfaction for those receiving a detailed explanation from their GP with a booklet giving advice on self-care. Both qualitative and quantitative data sets indicated higher patient enablement for those in the communication groups who had received a booklet. Use of CRP tests does not appear to engage patients or influence illness perceptions and its effect is more centred on changing clinician behaviour. Communication skills and the patient booklet were relevant and useful for all patients and associated with increased patient satisfaction. A triangulation protocol to integrate qualitative and quantitative data can reveal findings that need further interpretation and also highlight areas of dissonance that lead to a deeper insight than separate analyses.