Curbing Inappropriate Antibiotic Prescribing: What Works?


Am Fam Physician. 2016 Aug 1;94(3):203-204.

Related editorial: How to Prescribe Fewer Unnecessary Antibiotics: Talking Points That Work with Patients and Their Families.

The Centers for Disease Control and Prevention has campaigned to reduce inappropriate antibiotic prescribing for more than 20 years, yet antibiotic prescriptions for acute respiratory tract infections, which generally do not require antibiotic treatment, have decreased only modestly for children and not at all for adults.1,2 Physicians are aware of the problem of resistance to antibiotics, but cite pressure from patients and the need to ensure patient satisfaction as reasons for continuing to prescribe antibiotics when they are unlikely to help.3 Recognizing that educational approaches alone do not adequately change prescribing habits, researchers have studied other ways of persuading physicians to adhere to judicious prescribing recommendations. Some have turned to a strategy known as behavioral economics, which endorses noncoercive interventions that make it more cumbersome and costly to pursue undesirable choices while making preferred options readily available, convenient, and rewarding.4 Could this approach be effective in reducing antibiotic prescribing?

A recent study suggests that it can. In a cluster randomized controlled trial, 47 primary care practices were assigned to one of three behavioral interventions or no intervention.5 The primary outcome was inappropriate antibiotic prescribing for upper respiratory tract infections. The interventions included (1) an electronic health record–generated message suggesting that antibiotics were not indicated, with a menu of alternative symptomatic treatments; (2) accountable justification, in which a message asking physicians who persisted in prescribing the antibiotic to provide written justification or to choose “no justification given,” which would then become part of the patient record; and (3) peer-based feedback, in which physicians received a monthly e-mail notification ranking them as a “top performer” or “not a top performer.” A statistically significant reduction in antibiotic prescribing was noted in the accountable justification and peer-based feedback groups. The authors concluded that these interventions were successful because they involved social accountability, exposing physicians' prescribing choices to the scrutiny and judgment of others, whereas the message about alternative treatments generated only electronic feedback. A British study found that a letter from England's chief medical officer sent to 3,227 physicians informing them that they were prescribing more antibiotics than 80% of practices reduced antibiotic prescribing 3.3% compared with practices that did not receive a letter, representing an estimated 73,406 fewer antibiotics dispensed in one month.6

The results of these studies, which support the behavioral impact of social accountability, are consistent with yet another effective recommendation to reduce antibiotic prescribing: posters displayed in examination rooms, signed by the physician, committing to prescribe antibiotics appropriately.7,8 Social accountability is a subset of “nudging” techniques used to encourage rational antibiotic use. Another behavioral technique—this one actuallytargeting patients—is offering patients delayed antibiotic prescriptions, which gently compel patients to postpone and in many cases forego antibiotic treatment.9

The success of these interventions is not surprising. Physicians' concern about patient satisfaction and aversion to negative patient responses are reactions to perceived social pressure from patients. Behavioral techniques that draw on social accountability also apply social pressure, but from different sources, such as physicians' peers. That is not to say that other, less manipulative techniques do not work. Although electronic-based decision support methods did not affect antibiotic prescribing in the previously discussed study, another study showed that they reduced the use of broad-spectrum antibiotics compared with preferred narrow-spectrum choices over 27 months.10 However, techniques such as these do not involve peer accountability, which could explain why they have shown only marginal benefit.11 Educational interventions and point-of-care testing, such as C-reactive protein and procalcitonin testing in adults, have some evidence of effectiveness or at least warrant further study.12 The reasons for antibiotic overprescribing are multifactorial, so efforts to reduce inappropriate antibiotic prescribing should combine shared decision making, incentives, quality-control measures, and similar interventions designed to improve clinical practice.1315

editor's note: Caroline Wellbery, MD, PhD, is Associate Deputy Editor for AFP.

Address correspondence to Caroline Wellbery, MD, PhD, at wellberc@georgetown.edu. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.


show all references

1. Centers for Disease Control and Prevention. Office-related antibiotic prescribing for persons aged ≤14 years—United States, 1993–1994 to 2007–2008. MMWR Morb Mortal Wkly Rep. 2011;60(34):1153–1156....

2. Lee GC, Reveles KR, Attridge RT, et al. Outpatient antibiotic prescribing in the United States: 2000 to 2010. BMC Med. 2014;12:96.

3. Sanchez GV, Roberts RM, Albert AP, Johnson DD, Hicks LA. Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States. Emerg Infect Dis. 2014;20(12):2041–2047.

4. Loewenstein G, Brennan T, Volpp KG. Asymmetric paternalism to improve health behaviors. JAMA. 2007;298(20):2415–2417.

5. Meeker D, Linder JA, Fox CR, et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA. 2016;315(6):562–570.

6. Hallsworth M, Chadborn T, Sallis A, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet. 2016;387(10029):1743–1752.

7. Meeker D, Knight TK, Friedberg MW, et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med. 2014;174(3):425–431.

8. Fleming-Dutra KE, Mangione-Smith R, Hicks LA. How to prescribe fewer unnecessry antibiotics: talking points that work with patients and their families. Am Fam Physician. 2016;94(3):202–204.

9. Little P, Moore M, Kelly J, et al.; PIPS Investigators. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ. 2014;348:g1606.

10. Litvin CB, Ornstein SM, Wessell AM, Nemeth LS, Nietert PJ. Use of an electronic health record clinical decision support tool to improve antibiotic prescribing for acute respiratory infections: the ABX-TRIP study. J Gen Intern Med. 2013;28(6):810–816.

11. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;(6):CD000259.

12. McDonagh M, Peterson K, Winthrop K, Cantor A, Holzhammer B, Buckley DI. Improving antibiotic prescribing for uncomplicated acute respiratory tract infections. https://effectivehealthcare.ahrq.gov/ehc/products/561/2112/antibiotics-respiratory-infection-report-160128.pdf. Accessed April 27, 2016.

13. Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev. 2015;(11):CD010907.

14. Wise J. Hospitals and GPs are offered incentives to reduce antibiotic prescribing. BMJ. 2016;352:i1499.

15. van der Velden AW, Kuyvenhoven MM, Verheij TJ. Improving antibiotic prescribing quality by an intervention embedded in the primary care practice accreditation: the ARTI4 randomized trial. J Antimicrob Chemother. 2016;71(1):257–263.



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