Audit and Feedback Interventions for Antibiotic Prescribing in Primary Care: A Systematic Review and Meta-analysis

Alice X T Xu; Kevin Brown; Kevin L Schwartz; Soheila Aghlmandi; Sarah Alderson; Jamie Brehaut; Benjamin C Brown; Heiner C Bucher; Janet Clarkson; An De Sutter; Nick A Francis; Jeremy Grimshaw; Ronny Gunnarsson; Michael Hallsworth; Lars Hemkens; Sigurd Høye; Tasneem Khan; Donna Lecky; Felicia Leung; Jeremy Leung; Morten Lindbæk; Jeffrey A Linder; Carl Llor; Paul Little; Denise O'Connor; Céline Pulcini; Kalisha Ramlackhan; Craig R Ramsay; Pär-Daniel Sundvall; Monica Taljaard; Pia Touboul Lundgren; Akke Vellinga; Jan Y Verbakel; Theo J Verheij; Carl Wikberg; Noah Ivers

doi:10.1093/cid/ciae604

Audit and Feedback Interventions for Antibiotic Prescribing in Primary Care: A Systematic Review and Meta-analysis

Clin Infect Dis. 2024 Dec 5:ciae604. doi: 10.1093/cid/ciae604. Online ahead of print.

Authors

Alice X T Xu^{1

2}, Kevin Brown^{1

2}, Kevin L Schwartz^{1

2

3}, Soheila Aghlmandi⁴, Sarah Alderson⁵, Jamie Brehaut^{6

7}, Benjamin C Brown⁸, Heiner C Bucher⁹, Janet Clarkson^{10

11}, An De Sutter¹², Nick A Francis¹³, Jeremy Grimshaw^{6

14}, Ronny Gunnarsson^{15

16

17}, Michael Hallsworth^{18

19}, Lars Hemkens^{9

20

21

22}, Sigurd Høye²³, Tasneem Khan⁵, Donna Lecky²⁴, Felicia Leung²⁵, Jeremy Leung²⁶, Morten Lindbæk²³, Jeffrey A Linder²⁷, Carl Llor^{28

29

30}, Paul Little¹³, Denise O'Connor³¹, Céline Pulcini^{32

33}, Kalisha Ramlackhan¹, Craig R Ramsay³⁴, Pär-Daniel Sundvall^{15

16

17}, Monica Taljaard^{6

7}, Pia Touboul Lundgren³⁵, Akke Vellinga³⁶, Jan Y Verbakel^{37

38}, Theo J Verheij³⁹, Carl Wikberg^{15

16}, Noah Ivers⁴⁰

Affiliations

¹ Public Health Ontario, Toronto, Canada.
² Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
³ Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada.
⁴ Paediatric Research Center, University Children's Hospital Basel (UKBB), Basel, Switzerland.
⁵ Leeds Institute of Health Sciences, University of Leeds, UK.
⁶ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
⁷ School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
⁸ Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, UK.
⁹ Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Switzerland.
¹⁰ School of Dentistry, University of Dundee, UK.
¹¹ NHS Education for Scotland, UK.
¹² Department of Public Health and Primary Care, Center for Family Medicine UGent, Ghent University, Belgium.
¹³ Primary Care Research Centre, University of Southampton, UK.
¹⁴ Department of Medicine, University of Ottawa, Canada.
¹⁵ General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
¹⁶ Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden.
¹⁷ Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden.
¹⁸ The Behavioural Insights Team, Brooklyn, New York, USA.
¹⁹ University of Pennsylvania, Center for Social Norms and Behavioral Dynamics, Philadelphia, Pennsylvania, USA.
²⁰ Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland.
²¹ Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany.
²² Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA.
²³ Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Norway.
²⁴ Primary Care & Interventions Unit, HCAI, Fungal, AMR, AMU& Sepsis Division, UK Health Security Agency, UK.
²⁵ Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.
²⁶ Faculty of Science, McGill University, Montreal, Canada.
²⁷ Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
²⁸ University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain.
²⁹ CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.
³⁰ Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.
³¹ School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
³² Université de Lorraine, APEMAC, Nancy, France.
³³ Université de Lorraine, CHRU-Nancy, Centre régional en antibiothérapie du Grand Est AntibioEst, Nancy, France.
³⁴ Health Services Research Unit, University of Aberdeen, UK.
³⁵ Department of Public Health, Nice University Hospital, Nice, France.
³⁶ CARA Network, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Ireland.
³⁷ Department of Public Health and Primary Care, KU Leuven, Belgium.
³⁸ NIHR Community Healthcare Medtech and IVD cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.
³⁹ Julius Center for Health Sciences and Primary Care, UMC Utrecht, Netherlands.
⁴⁰ Women's College Hospital, Toronto, Canada.

PMID: 39657007
DOI: 10.1093/cid/ciae604

Abstract

Background: This systematic review evaluates the effect of audit and feedback (A&F) interventions targeting antibiotic prescribing in primary care and examines factors that may explain the variation in effectiveness.

Methods: Randomized controlled trials (RCTs) involving A&F interventions targeting antibiotic prescribing in primary care were included in the systematic review. Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and ClinicalTrials.gov were searched up to May 2024. Trial, participant, and intervention characteristics were extracted independently by two researchers. Random effects meta-analyses of trials that compared interventions with and without A&F were conducted for four outcomes: 1) total antibiotic prescribing volume; 2) unnecessary antibiotic initiation; 3) excessive prescription duration, and 4) broad-spectrum antibiotic selection. A stratified analysis was also performed based on study characteristics and A&F intervention design features for total antibiotic volume.

Results: A total of 56 RCTs fit the eligibility criteria and were included in the meta-analysis. A&F was associated with an 11% relative reduction in antibiotic prescribing volume (N=21 studies, rate ratio [RR]=0.89; 95% confidence interval [CI] 0.84, 0.95; I2=97); 23% relative reduction in unnecessary antibiotic initiation (N=16 studies, RR=0.77; 95%CI 0.68, 0.87; I2=72); 13% relative reduction in prolonged duration of antibiotic course (N=4 studies, RR=0.87 95%CI 0.81, 0.94; I2=86); and 17% relative reduction in broad-spectrum antibiotic selection (N=17 studies, RR=0.83 95%CI 0.75, 0.93; I2=96).

Discussion: A&F interventions reduce antibiotic prescribing in primary care. However, heterogeneity was substantial, outcome definitions were not standardized across the trials, and intervention fidelity was not consistently assessed.

Funding: Canadian Institutes of Health Research FRN 173704.

Registration: Prospero (CRD42022298297).

Keywords: Antibiotics; Audit and Feedback; Primary Care; Systematic Review.