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Evidence-Based Strategies in Using Persuasive Interventions to Optimize Antimicrobial Use in Healthcare: a Narrative Review

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A rise in antimicrobial resistance, seen especially since 2000, is in part caused by indiscriminate antimicrobial use. Varied types of persuasive interventions aimed to optimize antimicrobial use have been tried with varying success. Our review seeks to identify and assess factors associated with the successful implementation of persuasive interventions. We searched five databases (MEDLINE, EMBASE, The Cochrane Library, PsycINFO, and ERIC) to identify critical studies published between 2000 and December 2018 of interventions employing audit and feedback, education through meetings, academic detailing, reminders, and patient, family, or public education. Outcome measures of interest were any means to measure antimicrobial use. We included 26 articles in our analysis. Seventeen examined multimodal interventions and the most common was audit and feedback and meeting (four studies). Nine examined single interventions and the most common was audit and feedback (five studies). Our findings inform four evidence-based strategies to enable healthcare administrators, clinicians, and researchers to make informed choices when planning and designing an antimicrobial stewardship program: (1) implement a combination of persuasive interventions from both groups: audit and feedback, academic detailing, or patient, family, or provider education; and meeting or reminders, (2) design interventions that last one year or longer; post-intervention, assess the intervention’s long-term effects for at least another one year, (3) conduct quality improvement projects examining persuasive interventions if the prescribing database provides adequate diagnosis information, and most importantly, (4) make patient, family, or provider education an integral component of multimodal intervention.

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Fig. 1



Academic detailing


Audit and feedback


Controlled before-after


Interrupted time-series


Patient, family, or public education




Multimodal Interventions




Randomized controlled trial


  1. 1.

    Deuster, S., Roten, I., and Muehlebach, S., Implementation of treatment guidelines to support judicious use of antibiotic therapy. J Clin Pharm Ther 35:71–78, 2010.

  2. 2.

    Goossens, H., Ferech, M., Vander Stichele, R. et al., Outpatient antibiotic use in Europe and association with resistance: A cross-national database study. Lancet 365:579–587, 2005.

  3. 3.

    Medscape (2018) Antibiotic-resistant infections doubled since 2007 in Europe. https://www.medscape.com/viewarticle/904640. Accessed May 18 2019

  4. 4.

    Centers for Disease Control and Prevention (2013) Antibiotic resistance threats in the United States, 2013. http://www.cdc.gov/drugresistance/threat-report-2013/index.html. Accessed May 18 2019

  5. 5.

    Spurling, G. K., Del Mar, C. B., Dooley, L. et al., Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev 4:CD004417, 2013.

  6. 6.

    van de Sande-Bruinsma, N., Grundmann, H., Verloo, D. et al., System EARS: Antimocrobial drug use and resistance in Europe. Emerg Infect Dis 14:1722–1730, 2008.

  7. 7.

    World Health Organization (2015) Global action plan on antimicrobial resistance, 2015. http://apps.who.int/iris/bitstream/10665/193736/1/9789241509763_eng.pdf?ua=1. Accessed May 18 2019

  8. 8.

    Centers for Disease Control and Prevention (2019) The AMR Challenge. https://www.cdc.gov/drugresistance/intl-activities/amr-challenge.html. Accessed May 18 2019

  9. 9.

    Agency for Healthcare Research and Quality (2019) Nearly one in four antibiotic prescriptions were unnecessary in study of privately insured patients in 2016. https://www.ahrq.gov/news/newsroom/press-releases/antibiotic-prescriptions-study.html. Accessed May 18 2019

  10. 10.

    Chua, K.-P., Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study. BMJ 364:k5092, 2019.

  11. 11.

    Davey, P., Marwick, C. A., Scott, C. L. et al., Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2:CD003543, 2017.

  12. 12.

    Costello, C., Metcalfe, C., Lovering, A. et al., Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: Systematic review and meta-analysis. BMJ 340:c2096, 2010.

  13. 13.

    Roque, F., Herdeiro, M. T., Soares, S. et al., Educational interventions to improve prescription and dispensing of antibiotics: A systematic review. BMC Public Health 14:1276–1295, 2014.

  14. 14.

    van der Velden, A. W., Pijpers, E. J., Kuyvenhoven, M. M. et al., Effectiveness of physician-targeted interventions to improve antibiotic use for respiratory tract infections. Br J Gen Pract 62:801–807, 2012.

  15. 15.

    van Hees, B. C., de Ruiter, E., Wiltink, E. H. et al., Optimizing use of ciprofloxacin: A prospective intervention study. J Antimicrob chemother 61:210–213, 2008.

  16. 16.

    Naughton, C., Feely, J., and Bennett, K., A RCT evaluating the effectiveness and cost-effectiveness of academic detailing versus postal prescribing feedback in changing GP antibiotic prescribing. J Eval Clin Pract 15(5):807–812, 2009.

  17. 17.

    Welschen, I., Kuyvenhoven, M. M., Hoes, A. W. et al., Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: Randomised controlled trial. BMJ 329:431, 2004.

  18. 18.

    Fan, E., Laupacis, A., Pronovost, P. J. et al., How to use an article about quality improvement. JAMA 304:2279–2287, 2010.

  19. 19.

    Harbarth, S. H., Balkhy, H. H., Goossens, H. et al., Antimicrobial resistance: One world, one fight! Antimicrob Resist Infect Control 4:1–15, 2015.

  20. 20.

    Effective Practice and Organization of Care (2015) EPOC Taxonomy, 2015. epoc.cochrane.org/epoc-taxonomy. Accessed May 18 2019.

  21. 21.

    Garg, A. X., Adhikari, N. K., McDonald, H. et al., Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review. JAMA. 293(10):1223–1238, 2005.

  22. 22.

    Roshanov, P. S., Fernandes, N., Wilczynski, J. M. et al., Features of effective computerised clinical decision support systems: Metaregression of 162 randomised trials. BMJ (Clinical research ed) 346:f657, 2013.

  23. 23.

    Hemens, B. J., Holbrook, A., Tonkin, M. et al., Computerized clinical decision support systems for drug prescribing and management: A decision-maker-researcher partnership systematic review. Implement. Sci. 6:89, 2011.

  24. 24.

    Little, P., Stuart, B., Francis, N. et al., Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: A multinational, cluster, randomised, factorial, controlled trial. Lancet 382:1175–1182, 2013.

  25. 25.

    Regev-Yochay, G., Raz, M., Dagan, R. et al., Reduction in antibiotic use following a cluster randomized controlled multifaceted intervention: The Israeli judicious antibiotic prescription study. Clin Infect Dis 53:33–41, 2011.

  26. 26.

    Chazan, B., Turjeman, R. B., Frost, Y. et al., Antibiotic consumption successfully reduced by a community intervention program. Isr Med Assoc J 9:16–20, 2007.

  27. 27.

    Wei, X., Zhang, Z., Waller, J. D. et al., Effect of a training and educational intervention for physicians and caregivers on antibiotic prescribing for upper respiratory tract infections in children at primary care facilities in rural China: A cluster-randomised controlled trial. Lancet Glob Health 5:E1258–E1267, 2017.

  28. 28.

    Awad, A. I., Eltayeb, I. B., and Baraka, O. Z., Changing antibiotics prescribing practices in health centers of Khartoum state, Sudan. Eur J Clin Pharmacol 62:135–142, 2006.

  29. 29.

    Llor, C., Cots, J. M., González López-Valcárcel, B. et al., Effect of two interventions on reducing antibiotic prescription in pharyngitis in primary care. J Antimicrob Chemother 66:210–215, 2011.

  30. 30.

    Llor, C., Bjerrum, L., Molero, J. M. et al., Long-term effect of a practice-based intervention (HAPPY AUDIT) aimed at reducing antibiotic prescribing in patients with respiratory tract infections. J Antimicrob Chemother 73:2215–2222, 2018.

  31. 31.

    Formoso, G., Paltrinieri, B., Marata, A. M. et al., Feasibility and effectiveness of a low cost campaign on antibiotic prescribing in Italy: Community level, controlled, on-randomised trial. BMJ 347:f5391, 2013.

  32. 32.

    Dekker, A. R., Verheij, T. J., Broekhuizen, B. D. et al., Effectiveness of general practitioner online training and an information booklet for parents on antibiotic prescribing for children with respiratory tract infection in primary care: A cluster randomized controlled trial. J Antimicrob Chemother 73:1416–1422, 2018.

  33. 33.

    Papaevangelou, V., Rousounides, A., Hadjipanagis, A. et al., Decrease of antibiotic consumption in children with upper respiratory tract infections after implementation of an intervention program in Cyprus. Antimicrob Agents Chemother 56:1658–1661, 2012.

  34. 34.

    Altiner, A., Brockmann, S., Sielk, M. et al., Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: A cluster-randomized intervention study. J Antimicrob Chemother 60:638–644, 2007.

  35. 35.

    Borde, J. P., Kaier, K., Steib-Bauert, M. et al., Feasibility and impact of an intensified antibiotic stewardship programme targeting cephalosporin and fluoroquinolone use in a tertiary care university medical center. BMC Infect Dis 14:201, 2014.

  36. 36.

    Fowler, S., Webber, A., Cooper, B. S. et al., Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: A controlled interrupted time series. J Antimicrob Chemother 59:990–995, 2007.

  37. 37.

    Sartelli, M., Labricciosa, F. M., Scoccia, L. et al., Non-restrictive antimicrobial stewardship program in a general and emergency surgery unit. Surg Infect (Larchmt) 17:485–490, 2016.

  38. 38.

    Pettersson, E., Vernby, A., Mölstad, S. et al., Can a multifaceted educational intervention targeting both nurses and physicians change the prescribing of antibiotics to nursing home residents? A cluster randomized controlled trial. J Antimicrob Chemother 66:2659–2666, 2011.

  39. 39.

    Monette, J., Miller, M. A., Monette, M. et al., Effect of an educational intervention on optimizing antibiotic prescribing in long-term care facilities. J Am Geriatr Soc 55:1231–1235, 2007.

  40. 40.

    Elligsen, M., Walker, S. A., Pinto, R. et al., Audit and feedback to reduce broad-spectrum antibiotic use among intensive care unit patients: A controlled interrupted time series analysis. Infect Control Hosp Epidemiol 33:354–361, 2012.

  41. 41.

    Yeo, C. L., Chan, D. S., Earnest, A. et al., Prospective audit and feedback on antibiotic prescription in an adult hematology-oncology unit in Singapore. Eur J Clin Microbiol Infect Dis 31:583–589, 2012.

  42. 42.

    Hemkens, L. G., Saccilotto, R., Reyes, S. L. et al., Personalized prescription feedback using routinely collected data to reduce antibiotic use in primary care a randomized clinical trial. JAMA 177:176–183, 2017.

  43. 43.

    Camins, B. C., King, M. D., Wells, J. B. et al., Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: A randomized controlled trial. Infect Control Hosp Epidemiol 30:931–938, 2009.

  44. 44.

    Akter, A. F. U., Heller, R. D., Smith, A. J. et al., Impact of a training intervention on use of antimicrobials in teaching hospitals. J Infect Dev Ctries 3:447–451, 2009.

  45. 45.

    Cals, J. W., Butler, C. C., Hopstaken, R. M. et al., Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: Cluster randomised trial. BMJ 338:b1374, 2009.

  46. 46.

    Taggart, L. R., Leung, E., Muller, M. P. et al., Differential outcome of an antimicrobial stewardship audit and feedback program in two intensive care units: A controlled interrupted time series study. BMC Infect Dis 15:480, 2015.

  47. 47.

    Enriquez-puga, A., Baker, R., Paul, S. et al., Effect of educational outreach on general practice prescribing of antibiotics and antidepressants: A two-year randomised controlled trial. Scand J Prim Health Care 27:195–201, 2009.

  48. 48.

    Di Pentima, M. C., and Chan, S., Impact of antimicrobial stewardship program on vancomycin use in a pediatric teaching hospital. Pediatr Infect Dis J 29:707–711, 2010.

  49. 49.

    Arnold, S. R., and Straus, S. E., Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev 19:CD003539, 2005.

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The authors would like to acknowledge the help of Professor Matthew Lunde Ph.D. for reading and providing feedback on the manuscript.

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Correspondence to Jun Rong Jeffrey Neo.

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Appendix 1 List of search terms

Ovid MEDLINE® Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE® Daily and Ovid MEDLINE® - 1946 to Present

Date Searched: December 31, 2018

1exp Drug Resistance, Microbial/
2(“antimicrobial drug resistan*” or “antibiotic resistan*”).tw.
3(“bacterial drug resistan*” or “antibacterial drug resistan*”).tw.
4“beta Lactam resistan*”.tw.
5“cephalosporin resistan*”.tw.
6“penicillin resistan*”.tw.
7“ampicillin resistan*”.tw.
8“methicillin resistan*”.tw.
9“chloramphenicol resistan*”.tw.
10“kanamycin resistan*”.tw.
11“tetracycline resistan*”.tw.
12“trimethoprim resistan*”.tw.
13“vancomycin resistan*”.tw.
14(“fungal drug resistan*” or “antifungal drug resistan*”).tw.
15“multidrug resistan*”.tw.
16“antiviral drug resistan*”.tw.
19(educat* or workshop or workshops or train* or “literacy program” or “literacy programs” or stewardship or teach*).tw.
20Education, Predental/
21Education, Premedical/
22Education, Professional/
23Clinical Clerkship/
24(“clinical clerkship” or “clinical clerkships” or “clinical apprenticeship” or “clinical apprenticeships”).tw.
25exp Education, Continuing/
26exp Education, Graduate/
27Education, Medical/
28Education, Nursing/
29Education, Pharmacy/
30Education, Public Health Professional/
32(mentor or mentoring or mentorship or mentors or coaching).tw.
34(preceptorship or “medical field study” or “medical field studies” or “clinical practicum” or “clinical practicums” or “medical field work”).tw.
35Teacher Training/
36Inservice Training/
37(“orientation program” or “orientation programs” or “employee orientation”).tw.
38Staff Development/
39(“staff development” or “employee cross training”).tw.
43(communicate or communicating or communication or communications).tw.
44Information Dissemination/
45(“information dissemination” or “information distribution” or “information sharing” or “information sharings” or “data sharing” or “data sharings”).tw.
46Health Literacy/
47“health literacy”.tw.
4941 or 48
5017 and 49
51limit 50 to yr = “2006 -Current”
52animals/ not humans/
5351 not 52

Appendix 2

Table 1 Characteristics of included studies

Appendix 3

Table 2 Summary of results

Appendix 4

Table 3 Study findings

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Neo, J.R.J., Niederdeppe, J., Vielemeyer, O. et al. Evidence-Based Strategies in Using Persuasive Interventions to Optimize Antimicrobial Use in Healthcare: a Narrative Review. J Med Syst 44, 64 (2020). https://doi.org/10.1007/s10916-020-1531-y

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  • Antimicrobial resistance
  • Antimicrobial management
  • Antibiotic prescription
  • Antibiotic usage
  • Persuasive interventions
  • Antibiotic resistance