From: Antimicrobial stewardship in rural and remote primary health care: a narrative review
Reference # | First author | Year | Study type | JBI checklist used (score/total) | Country | Participants (number, sites) | Intervention description | Outcome measures | Main findings |
---|---|---|---|---|---|---|---|---|---|
Patient and provider education | |||||||||
Rural and remote | |||||||||
[70] | Belongia | 2001 | Non-randomised, controlled trial | Quasi-experimental Study (8/9) | United States | Parents and 151 primary care clinicians who provide paediatric care in a rural area | Clinician and community education via educational meetings and printed educational materials | Number of solid and liquid prescriptions per clinician, retail antibiotic sales, nasopharyngeal carriage of penicillin-nonsusceptible Streptococcus pneumoniae | Median number of solid antibiotic prescriptions per clinician decreased 19% in the intervention region and 8% in the control region. Median number of liquid antibiotic prescriptions per clinician decreased 11% in the intervention region but increased 12% in the control region. Retail antibiotic sales dropped in the intervention region but not in the control region |
[62] | Chiswell | 2019 | Retrospective pretest–posttest study | Quasi-experimental Study (7/9) | United States | 207 ‘walk-in’ patients in a rural primary care practice diagnosed with a respiratory tract infection | One-year patient education intervention programme involving repeated exposure to posters and handouts containing relevant health information | The number of antibiotics prescribed for respiratory tract infections | Antibiotic prescription rate decreased from 56.3% in the preintervention group to 28.8% in the postintervention group (x2 = 15.97, P < 0.001). The number of immediate antibiotic prescriptions dropped from 31.1% in the preintervention group to 13.5% in the postintervention group (x2 = 9.28, P < 0.05) |
[65] | Wei | 2017 | Cluster randomised controlled trial | Randomized Controlled Trial (11/13) | China | Children aged 2–14 years given a prescription following a primary diagnosis of an upper respiratory tract infection in 25 primary care township hospitals across 2 rural counties | Clinician guidelines and training on appropriate prescribing, monthly prescribing peer-review meetings, and brief patient/caregiver education | Primary outcome: Antibiotic prescription rate Secondary outcomes: Rates of prescribing multiple antibiotics, broad-spectrum antibiotics and intravenous antibiotics, proportion of prescriptions containing nonantibiotic medicines, cost | Antibiotic prescription rate decreased from 82 to 40% in the intervention group, and from 75 to 70% in the control group, yielding an absolute risk reduction in antibiotic prescribing of − 29% (95% CI − 42 to − 16; P = 0.0002) |
[66] | Wei (subgroup follow-up analysis of above study) | 2019 | Cluster randomised controlled trial | Randomized Controlled Trial (11/13) | China | Children aged 2–14 years given a prescription following a primary diagnosis of an upper respiratory tract infection in 14 primary care township hospitals across 1 rural county | Clinician guidelines and training on appropriate prescribing, monthly prescribing peer-review meetings, and brief patient/caregiver education | Primary outcome: Antibiotic prescription rate Secondary outcomes: Factors in sustaining intervention, rates of prescribing multiple antibiotics, broad-spectrum antibiotics and intravenous antibiotics, proportion of prescriptions containing nonantibiotic medicines, cost | The APR difference in the intervention arm at 6 months is − 49% (95% CI − 63 to − 35; P < 0.0001) compared to baseline. Compared to baseline, the APR difference in the intervention arm at 18 months is − 36% (95% CI − 55 to − 17; P < 0.0001). Compared to that at 6 months, the difference at 18 months represented no change in the APR. Factors sustaining reductions included doctors’ improved knowledge and communication skills and focused prescription review meetings, whereas lack of supervision and monitoring may be associated with relapse |
[68] | Cummings | 2020 | Quasi-experimental | Quasi-experimental Study (6/9) | United States | Rural urgent care centres | Three behavioural interventions: (1) physician and patient education via lectures, presentations, media and distributable materials, (2) public commitment from the Medical Director of Urgent Care, and (3) peer comparison via individual feedback and blinded ranking emails | Proportion of acute respiratory tract infection diagnosis visits that received an inappropriate antibiotic | Percentage of inappropriate prescribing decreased 14.9%, from 72.6 to 57.7% (95% CI − 20.30% to − 9.05%; t, 5.44; P < 0.0001). Interrupted time series analysis showed a significantly lowered rate of antibiotic-inappropriate prescribing (95% CI − 4.59 to − 0.59; P = 0.014) |
[74] | Zhang | 2018 | Cluster randomised controlled trial | Randomized Controlled Trial (11/13) | China | Children aged 2–14 years given a prescription following a primary diagnosis of an upper respiratory tract infection in 25 primary care township hospitals across 2 rural counties | Clinician guidelines and training on appropriate prescribing, monthly prescribing peer-review meetings, and brief patient/caregiver education | Cost per percentage point decrease in the antibiotic prescription rate | Incremental cost of US$0.03 per percentage point reduction in antibiotic prescribing |
Mixed urban and rural | |||||||||
[67] | Varonen | 2007 | Randomised controlled trial | Randomized Controlled Trial (8/13) | Finland | 30 rural and urban health centres | Nationwide guidelines implementation programme involving education based on a PBL or AD method facilitated by local general practitioners | Compliance with acute maxillary sinusitis management in national Current Care guidelines | Slight increase in the use of the first-line drug amoxicillin (39–48% in AD centres, 33–45% in PBL centres, controls 40%). Proportion of antibiotic courses with recommended duration increased (34–40% in AD centres, 32–47% in PBL centres, controls 43%) |
[73] | Little | 2001 | Randomised controlled trial | Randomized Controlled Trial (9/13) | England | 315 children presenting with acute otitis media in 42 general practices (33% mixed urban and rural settings) | Two treatment strategies – immediate antibiotics or delayed antibiotics – supported by standardised advice sheets | Resolution of symptoms, absence from school or nursery, paracetamol consumption | Children prescribed antibiotics immediately had shorter illness [− 1.1 days (95% CI − 0.54 to − 1.48)], fewer nights disturbed (− 0.72 (95% CI − 0.30 to − 1.13)], and slightly less paracetamol consumption [− 0.52 spoons/day (95% CI: − 0.26 to − 0.79)], but had higher incidence of diarrhoea (14/150 (9%) v 25/135 (19%), x2 = 5.2, P = 0.02), compared to delayed prescription |
[75] | Haenssgen | 2018 | Quasi-experimental qualitative study | Quasi-experimental Study (7/9) | Laos | 1130 peri-urban villagers | A one-off educational activity comprising of six sections—a mapping exercise, a medicine matching game, a resistance game, a role-play activity, a healthy-wealthy game and a feedback session | Attitudes and knowledge on antibiotics, treatment-seeking behaviour, and social networks | Awareness and understanding of antibiotic resistance improved, but effects on attitudes were minor. Mixed impact on behavioural changes. Activity-related communication spread within groups of greater privilege |
Physician support systems | |||||||||
Rural and remote | |||||||||
[64] | Samore | 2005 | Cluster randomised trial | Randomized Controlled Trial (7/13) | United States | 407,460 inhabitants and 334 primary care clinicians in 12 rural communities | 6 communities received a community intervention alone and 6 communities received community intervention plus CDSS targeted toward primary care clinicians | Community-wide and diagnosis-specific antimicrobial usage | Prescribing rate decreased from 84.1 to 75.3 per 100 person-years in the CDSS arm vs 84.3 to 85.2 in community intervention alone (P = 0.03). Antimicrobial prescribing for visits in the antibiotics “never-indicated” category during the postintervention period decreased 32% in CDSS communities and 5% in community intervention-alone communities (P = 0.03). Macrolide use decreased significantly in CDSS communities (P = 0.001) but not in community intervention–alone communities |
[69] | Gonzales | 2013 | Cluster randomised controlled trial | Randomized Controlled Trial (9/13) | United States | 33 primary care practices in a rural region | Simple clinical algorithm implemented via a traditional printed decision support (PDS) or a computer-assisted decision support (CDS) strategy integrated into the workflow of an electronic health record | Antibiotic prescription rates for uncomplicated acute bronchitis | Percentage of antibiotic prescription decreased compared to baseline at the PDS intervention sites (from 80.0 to 68.3%) and at the CDS intervention sites (from 74.0 to 60.7%) but increased slightly at the control sites (from 72.5 to 74.3%). Differences due to interventions were statistically significant from the control sites (P = 0.003 and P = 0.01 for PDS and CDS, respectively) but not between themselves (P = 0.67) |
[72] | Rubin (Extension analysis of study described in Reference #64) | 2006 | Observational quantitative study | Randomized Controlled Trial (7/13) | United States | 99 primary care providers serving rural communities | A standalone personal digital assistant-based CDSS tool for the diagnosis and management of acute respiratory tract infections | Usage patterns and acceptability of the tool | Adherences with CDSS recommendations for the five most common diagnoses and for antibiotic choice were 82% and 76%, respectively. Logistic regression models indicate that provider adherence improved with each ten cases entered into the system (P = 0.001). Respondents believed the CDSS was easy to use, and most (44/65; 68%) reported that patient encounters were either the same duration or slightly faster, when using the CDSS tool compared with their usual practice |
[76] | Madaras-Kelly | 2006 | Experimental quantitative cohort study | Quasi-experimental Study (8/9) | United States | 192 patients visiting 2 rural community pharmacies for broad-spectrum antibiotics | Community pharmacists conducted guided interviews regarding patient symptoms and intercepted inappropriate prescriptions through communication with the ordering clinician to decrease broad-spectrum antibiotic use in upper respiratory infections | Number of patients agreeable for interview, pharmacist time, primary care provider acceptance of the recommendations, and patient opinion data regarding the pharmacy intervention | 3% of the patients who were approached declined to discuss their symptoms and treatment with the pharmacist. 7% (n = 4) of patients permitted the community pharmacist to contact the prescriber to discuss first-line therapeutic alternatives. 2 of 3 clinicians contacted by pharmacists were receptive to altering the broad-spectrum antimicrobial to first-line antimicrobial therapy |
Surveillance | |||||||||
Rural and remote | |||||||||
[45] | Cuningham | 2020 | Retrospective data analysis | Prevalence Study (9/9) | Northern Australia | 15 remote primary health care clinics | The General Practice version of the National Antimicrobial Prescribing Survey (GP NAPS) tool modified for remote primary health care clinics | Antimicrobials used, indications and the treating health professional to yield similarities and differences in prescribing patterns, appropriateness of antimicrobial use and functionality of the GP NAPS tool | The adapted GP NAPS tool demonstrated potential as an audit tool of antimicrobial use for the remote primary health care setting in Australia. Compared with other Australian settings, narrow spectrum antimicrobials were more commonly prescribed with high appropriateness of use (WA: 91%; NT: 82%; QLD: 65%). The dominant treatment indications were skin and soft tissue infections (WA: 35%; NT: 29%; QLD: 40%) |
[77] | Hui | 2015 | Mathematical model | Diagnostic Test Accuracy Test (7/10) | Australia | Simulated remote indigenous community | Individual-based mathematical model to determine the impact of molecular testing on AMR surveillance of gonorrhoea | Time delay between first importation and the first confirmation that the prevalence of gonorrhoea AMR has breached the 5% threshold (when a change in antibiotic should occur) | In the best-case scenario, the alert would be triggered within 3–6 months of the resistance proportion exceeding the 5% threshold, at least 8 months earlier than using culture alone |
Mixed urban and rural | |||||||||
[78] | Schwartz | 2019 | Database validation | Diagnostic Test Accuracy Test (6/10) | Canada | 9272 physicians prescribing antibiotics to patients ≥ 65 years in urban (90.3%) and rural (9.7%) locations of practice | IQVIA Xponent database of dispensed antibiotic prescription counts aggregated at the physician prescriber-level | Agreement and correlation between Xponent and Ontario Drug Benefit database, performance characteristics for Xponent to accurately identify high prescribing physicians | The Xponent database has a specificity of 92.4% (95% CI 92.0–92.8%) and PPV of 77.2% (95% CI 76.0–78.4%) for correctly identifying the top 25th percentile of physicians by antibiotic volume. In the sensitivity analysis, 94% of the top 25th percentile physicians in Xponent were within the top 40th percentile in the reference database. The mean number of antibiotic prescriptions per physician were similar, but the error was greater in rural areas |
National policies | |||||||||
Mixed urban and rural | |||||||||
[63] | Hammond | 2020 | Ecological retrospective database analysis | Prevalence Study (6/9) | United Kingdom | 163 urban (80.61%) and rural (14.12%) primary care practices | Incentivising reduced primary care prescribing of co-amoxiclav, cephalosporins and quinolones for any infection | Primary care antibiotic dispensing and antibiotic resistance in community-acquired urinary Escherichia coli | Overall antibiotic dispensing per 1000 registered patients decreased 11%. Antibiotic reductions were associated with reduced within quarter antibiotic resistance to amoxicillin, ciprofloxacin and trimethoprim, reduced subsequent quarter resistance to trimethoprim and amoxicillin, and increased within and subsequent quarter resistance to cefalexin and co-amoxiclav |
[68] | Yin | 2018 | Retrospective database analysis | Prevalence Study (6/9) | China | 500 secondary and tertiary hospitals, 600 urban PHC centres and 1600 rural PHC centres | Zero mark-up policies and national policy to improve the rational use of antibiotics in primary health care centres | Data on total and specific antibiotic consumption | Overall antibiotic consumption increased from 12.859 DID in 2012 to 15.802 DID in 2014. When national policies were introduced, this decreased to 13.802 DID in 2016. After an upward trend for 3 years, oral and parenteral antibiotic consumption decreased in rural PHC centres by 12% and 33% from 2014 to 2016 |