Archive for April 22, 2016

Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial

Lancet April 23, 2016 V.387 N.10029 P.1743–1752


Michael Hallsworth, Tim Chadborn, PhD, Anna Sallis, Michael Sanders, PhD, Daniel Berry, Felix Greaves, PhD, Lara Clements, Prof Sally C Davies, MD


Unnecessary antibiotic prescribing contributes to antimicrobial resistance. In this trial, we aimed to reduce unnecessary prescriptions of antibiotics by general practitioners (GPs) in England.


In this randomised, 2 × 2 factorial trial, publicly available databases were used to identify GP practices whose prescribing rate for antibiotics was in the top 20% for their National Health Service (NHS) Local Area Team. Eligible practices were randomly assigned (1:1) into two groups by computer-generated allocation sequence, stratified by NHS Local Area Team. Participants, but not investigators, were blinded to group assignment. On Sept 29, 2014, every GP in the feedback intervention group was sent a letter from England’s Chief Medical Officer and a leaflet on antibiotics for use with patients. The letter stated that the practice was prescribing antibiotics at a higher rate than 80% of practices in its NHS Local Area Team. GPs in the control group received no communication. The sample was re-randomised into two groups, and in December, 2014, GP practices were either sent patient-focused information that promoted reduced use of antibiotics or received no communication. The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population, controlling for past prescribing. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN32349954, and has been completed.


Between Sept 8 and Sept 26, 2014, we recruited and assigned 1581 GP practices to feedback intervention (n=791) or control (n=790) groups. Letters were sent to 3227 GPs in the intervention group. Between October, 2014, and March, 2015, the rate of antibiotic items dispensed per 1000 population was 126·98 (95% CI 125·68–128·27) in the feedback intervention group and 131·25 (130·33–132·16) in the control group, a difference of 4·27 (3·3%; incidence rate ratio [IRR] 0·967 [95% CI 0·957–0·977]; p<0·0001), representing an estimated 73 406 fewer antibiotic items dispensed. In December, 2014, GP practices were re-assigned to patient-focused intervention (n=777) or control (n=804) groups. The patient-focused intervention did not significantly affect the primary outcome measure between December, 2014, and March, 2015 (antibiotic items dispensed per 1000 population: 135·00 [95% CI 133·77–136·22] in the patient-focused intervention group and 133·98 [133·06–134·90] in the control group; IRR for difference between groups 1·01, 95% CI 1·00–1·02; p=0·105).


Social norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale; this outcome makes it a worthwhile addition to antimicrobial stewardship programmes.


Public Health England.



April 22, 2016 at 8:01 am

Strong stewardship to fight antimicrobial resistance

Lancet April 23, 2016 V.387 N.10029


Antibiotics have undoubtedly revolutionised medicine. However, widespread use of antimicrobial drugs in medicine and agriculture has spurred the evolution of pan-resistant bacterial strains. With few new antibiotics in the development pipeline, the threat to public health of antimicrobial resistance is all too real. Strong stewardship policies are urgently needed to stem inappropriate prescribing and use of antibiotics.


On April 13, the Infectious Diseases Society of America and the Society for Health Care Epidemiology of America released a new guideline: Implementing an Antibiotic Stewardship Program, with 27 recommendations that cover a broad range of antibiotic stewardship interventions. Among the recommendations are use of preauthorisation for antibiotic prescribing, restriction of use of antibiotics with high risk of Clostridium difficile infection, and strategies for specific health-care settings (such as nursing homes) to reduce unnecessary or inappropriate antibiotic use. Of note, although these recommendations can be used across a range of clinical settings, the authors highlight the lack evidence for effective antibiotic stewardship interventions, and call for increased research to determine how to best achieve large-scale implementation of these measures.


April 22, 2016 at 8:00 am

Antibiotic stewardship: prescribing social norms

Lancet April 23, 2016 V.387 N.10029


Ian M Gould, Timothy Lawes

With a burgeoning world population, expansions in medical intervention, and intensified agriculture, the need for antibiotic stewardship is increasingly clear. Declining efficacy of antimicrobial prophylaxis for surgery or chemotherapy, and emergence of pan-resistant pathogens, warn of a post-antibiotic era. In the evolutionary arms race of antimicrobial resistance, rejuvenating the neglected pipeline for new agents provides only a partial solution. The key challenge worldwide is translating awareness of resistance into effective stewardship.

In the past decade, the UK has made notable progress. A high media profile has provided political leverage to advance antimicrobial resistance up national health agendas, and surveillance systems for antibiotic consumption and resistance have been established. National targets to reduce broad-spectrum antibiotic use have been associated with declines in Clostridium difficile and meticillin-resistant Staphylococcus aureus. However, declining sensitivities to substitute antibiotics4 suggest that without reducing total antibiotic consumption, we might be replacing rather than eliminating resistances. Sustaining progress will require a major shift in prescribing and consumption norms …


April 22, 2016 at 7:59 am


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