Evaluation of a multimodal intervention to promote rational antibiotic use in primary care

Exploring the association between phytopharmaceutical use and antibiotic prescriptions in upper respiratory infections: results from a German cohort study evaluating the impact of naturopathy qualifications of general practitioners using routine data

Background

Antibiotic resistance is a significant global health threat, exacerbated by inappropriate prescribing practices, particularly for upper respiratory infections that are predominantly viral. Complementary and Integrative Medicine (CIM), including the use of phytopharmaceuticals, offers a potential strategy to reduce antibiotic prescriptions.

Objective

This study aimed to describe the impact of General Practitioners' (GPs) naturopathy (NP) qualifications and phytopharmaceutical prescriptions on the rate of antibiotic prescribing for upper respiratory infections (RTI).

Methods

We conducted a retrospective cohort study using routine data from the CONTinuous morbidity registration Epidemiologic NeTwork (CONTENT), which includes over 200,000 patients across four federal states in Germany. The study included data from n = 36 GPs who recorded at least one ICD-10 diagnosis of RTI. Antibiotic and phytopharmaceutical prescriptions were identified and analyzed through mixed-effects logistic regression models to explore the influence of GPs' naturopathy qualifications and phytopharmaceutical use on antibiotic prescribing patterns.

Results

The study included 40,344 patients managed by 36 GPs. Prescriptions of phytopharmaceuticals significantly reduced the likelihood of antibiotic use (OR 0.48, 95% CI 0.45-0.52). Additionally, holding a naturopathy qualification was associated with lower rates of antibiotic prescriptions (OR 0.73, 95% CI 0.69-0.78). The interaction between naturopathy qualification and phytopharmaceutical prescriptions also showed a significant effect (OR 1.43, 95% CI 1.27-1.62). Patient's year of birth influenced prescribing patterns indicating a reduction of antibiotic prescriptions for younger patients, while patients' gender did not reveal a significant effect.

Conclusion

Prescriptions of phytopharmaceuticals were significantly associated with a decrease antibiotic prescriptions among GPs, especially when combined with naturopathy qualifications. Training in naturopathic approaches could enhance antibiotic stewardship efforts in primary care settings, suggesting that broader integration of CIM elements into medical training could be beneficial in mitigating antibiotic resistance.

GPs' Perspective on a Multimodal Intervention to Enhance Guideline-Adherence in Uncomplicated Urinary Tract Infections: A Qualitative Process Evaluation of the Multicentric RedAres Cluster-Randomised Controlled Trial

Urinary tract infections (UTIs) are among the most common reasons patients seeking health care and antibiotics to be prescribed in primary care. However, general practitioners' (GPs) guideline adherence is low. The RedAres randomised controlled trial aims to increase guideline adherence by implementing a multimodal intervention consisting of four elements: information on current UTI guidelines (1) and regional resistance data (2); feedback regarding prescribing behaviour (3); and benchmarking compared to peers (4). The RedAres process evaluation assesses GPs' perception of the multimodal intervention and the potential for implementation into routine care. We carried out 19 semi-structured interviews with GPs (intervention arm). All interviews were carried out online and audio recorded. For transcription and analysis, Mayring's qualitative content analysis was used. Overall, GPs considered the interventions helpful for knowledge gain and confirmation when prescribing. Information material and resistance were used for patient communication and teaching purposes. Feedback was considered to enhance reflection by breaking routines of clinical workup. Implementation into routine practice could be enhanced by integrating feedback loops into patient management systems and conveying targeted information via trusted channels or institutions. The process evaluation of RedAres intervention was considered beneficial by GPs. It confirms the convenience of multimodal interventions to enhance guideline adherence.

Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice

BACKGROUND

Trials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care.

METHODS

We drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified 'guiding principles' with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals.

RESULTS

Focus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an 'implementation support' website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and material resources (patient leaflets, POC-CRPT equipment, clinician handouts).

CONCLUSIONS

We used a systematic, user-focussed process of developing a behavioural intervention, illustrating how it can be used in an implementation context. This resulted in a multicomponent intervention to facilitate practice-wide implementation of evidence-based strategies which now requires implementing and evaluating. Focusing on supporting the uptake and implementation of evidence-based strategies to optimise antibiotic use in general practice is critical to further support appropriate antibiotic use and mitigate antimicrobial resistance.