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Interventions reduce antibiotic prescriptions for ARIs


The percentage of adolescents and adults prescribed antibiotics for acute bronchitis decreased at intervention sites where printed and computer-assisted decision support was offered, according to a study.

The overuse of antibiotics for acute respiratory tract infections contributes to worsening trends in antibiotic-resistance, according to background information for the study, which is scheduled for publication in JAMA Internal Medicine (formerly the Archives of Internal Medicine). About 30% of office visits for colds and for nonspecific upper respiratory tract infections, along with up to 80% of all visits for bronchitis, are treated with antibiotics. Efforts have helped reduce antibiotic use for some ARIs, but reducing antibiotic treatment for acute bronchitis has remained a challenge, according to the authors.

Ralph Gonzales, MD, MSPH, of the University of California, San Francisco, and colleagues conducted a three-group cluster randomized study at 33 primary care practices in an integrated healthcare system in central Pennsylvania.

At 11 practices, the intervention was printed decision support in which educational brochures were given by triage nurses to patients with cough illnesses as part of routine care, and a poster displaying the clinical algorithm for distinguishing acute bronchitis versus pneumonia was in all the examination rooms. At 11 practices with a computer-assisted decision support intervention, when triage nurses entered “cough” into the electronic health record, an alert would prompt the nurse to provide an educational brochure to the patient; in addition, the algorithm was programmed into the EHR. There also were 11 control sites.

The trial compared antibiotic prescription rates for uncomplicated acute bronchitis during the winter period (October 2009 through March 2010) following the intervention with the previous three winter periods.

Compared with the baseline period, the researchers wrote, the percentage of adolescents and adults prescribed antibiotics for uncomplicated acute bronchitis during the intervention period decreased at the printed decision support intervention sites (from 80% to 68.3%) and computer-assisted decision support intervention sites (from 74% to 60.7%), and increased slightly at the control sites (from 72.5% to 74.3%).

Differences for the intervention sites were statistically significant from the control sites but not between the printed decision support and computer-assisted decision support intervention sites, according to the data.

“We found that printed and computer-assisted approaches were equally effective at improving antibiotic treatment of uncomplicated acute bronchitis,” the authors wrote. “In aggregate, these findings support the wider dissemination and use of this clinical algorithm to help reduce the overuse of antibiotics for acute bronchitis in primary care.”

In an invited commentary, Jeffrey A. Linder, MD, MPH, of Brigham and Women’s Hospital and Harvard Medical School in Boston, noted that antibiotic prescribing for acute bronchitis nationwide remains at more than 70%.

Some of the study results “should give us pause,” he wrote, because the “antibiotic prescribing rate — an event that should never happen for these patients — in ‘successful’ intervention practices was still more than 60%.

“We should address patients’ symptoms, but for antibiotics we need to tell our patients that ‘this medicine is more likely to hurt you than to help you.’ Success is not reducing the antibiotic prescribing rate by 10%; success is reducing the antibiotic prescribing rate to 10%.”

The study abstract is available at


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