A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada

Warren Mcisaac,Yoshiko Nakamachi,Andrew M Morris,Mruna Shah,Braden O’Neill,Rosemarie Lall,Ruby Alvi,Sophia Virani,Noah Ivers,Leah Szadkowski,Navsheer Toor,Aashka Bhatt,Sahana Kukan,Ella Huszti

doi:10.1186/s12875-021-01536-3

Abstract

BackgroundMore than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care.MethodsPrimary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences.ResultsThere were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37).ConclusionsA community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations.Trial registrationclinicaltrials.gov (NCT03517215).

Highlights

More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary
We previously developed a multi-faceted primary care provider-focused antimicrobial stewardship intervention that addressed clinical uncertainty through use of clinical decision aids, delayed prescriptions and safety netting advice [16]
Study setting and design The University of Toronto Practice-based Research Network (UTOPIAN) consists of 14 family medicine clinics in south central Ontario affiliated with the Department of Family and Community Medicine of the University of Toronto

Summary

Introduction

More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. The need to more appropriately use antibiotics in order to limit antibiotic resistance has been widely endorsed [1, 2]. Progress towards this goal has been slow. The recognition that 90% of antibiotic use occurs in the community has focused attention on primary care prescribers [4]. A 2019 U.S study found 59% of outpatient antibiotic prescriptions are likely not needed [5]. Reducing this volume of unnecessary antibiotic use may be critical to limit antibiotic resistance. Effective community antimicrobial stewardship (AMS) approaches are needed

Objectives

Methods

Results