Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 4: Antibiotic Prescribing Behavior)

Unnecessary prescribing of antibiotics is a major problem in the US and worldwide, contributing to the problem of antimicrobial resistance (AMR). This review examines the effects of quality improvement strategies on reducing inappropriate prescribing of antibiotics, targeting both prescribing of antibiotics for non-bacterial illnesses (“the antibiotic treatment decision”) and prescribing of broad-spectrum antibiotics when narrow-spectrum agents are indicated (“the antibiotic selection decision”).


We evaluated studies examining the effectiveness of quality improvement (QI) strategies targeting outpatient antibiotic prescribing for acute illnesses. Studies were identified by searching the Cochrane Collaboration's Effective Practice and Organisation of Care registry and MEDLINE®. We included randomized and quasi-randomized controlled trials, controlled before-after studies, and interrupted time series that reported measures of antimicrobial use. QI strategies were classified as clinician education, patient education, provision of delayed prescriptions, audit and feedback, clinician reminders, and financial or regulatory incentives. Our primary outcomes were the percentage of patients prescribed an antibiotic (for antibiotic treatment studies); or the percentage of patients prescribed a recommended antibiotic or guideline-concordant antibiotic therapy (for antibiotic selection studies). Secondary outcomes included effects on antimicrobial resistance, intervention safety (disease outcomes and adverse events), prescribing costs, and patient satisfaction.


Two reviewers abstracted data on the components of the QI intervention, study population, targets, and outcomes. We compared the effects of QI strategies in terms of the median effect achieved for the primary outcomes, using nonparametric tests; studies not eligible for median effects analysis were summarized qualitatively.


Fifty-four studies reporting a total of 74 trials met the inclusion criteria; 34 studies (reporting 41 trials) addressed the treatment decision, and 26 studies (reporting 33 trials) addressed the selection decision. Six studies evaluated both decisions. Study methodologic quality was generally fair. Nearly all studies took place in outpatient primary care clinics. Studies addressing the antibiotic treatment decision: Most studies addressed prescribing for acute respiratory infections (ARIs). Interventions were effective at reducing prescribing, with a median absolute effect of -8.9% [interquartile range (IQR) -12.4% to -6.7%]. No individual QI strategy (or combination of strategies) was more effective at reducing prescribing. Within clinician education, active educational strategies appeared more effective than passive strategies. When extrapolated to a population level, strategies targeting general antibiotic prescribing appeared to reduce antibiotic prescribing more than strategies targeting prescribing for a single condition. Few studies addressed secondary endpoints; patient satisfaction was not worsened by QI interventions, but effects on AMR or costs could not be assessed. Studies addressing the antibiotic selection decision: Interventions targeted prescribing for ARIs or urinary tract infections (UTIs). Interventions were effective, with a median absolute improvement in prescribing of recommended antibiotics of 10.6% (IQR 3.4% to 18.2%). Clinician education alone appeared more effective than education in combination with audit and feedback, but this finding likely represents confounding. Very few studies addressed secondary outcomes.


Quality improvement efforts appear generally effective at reducing both inappropriate treatment with antibiotics and inappropriate selection of antibiotics. While no single QI strategy was more effective than others, active clinician education may be more effective than passive education, particularly for addressing the antibiotic treatment decision. Greater reductions in overall prescribing may be achieved through efforts targeting prescribing for all acute respiratory infections, rather than targeting single conditions. The available evidence is of only fair quality, and further research on the cost-effectiveness and potential harms of these interventions is needed.


HuisartsengeneeskundeInfectieziekten en Medische microbiologieEducational gatheringsEducational literature distributionsFeedbackOrganizational interventionsPatient directed interventionsRemindersOverigBehandeling medicatie



Ranji SR
Steinman MA
Shojania KG
Sundaram V
Lewis R
Arnold S
Gonzales R