Objectives To evaluate the effect of general practice-level prescribing feedback on antibiotic prescribing in a real-world pragmatic cluster randomized controlled trial Methods Three hundred and forty general practices in four territorial Health Boards in NHS Scotland were randomized in Quarter 1, 2016 to receive four quarterly antibiotic-prescribing feedback reports or not, from Quarter 2, 2016 to Quarter 1, 2017. Reports included different clinical topics, benchmarking against national and health board rates, and behavioural messaging with improvement actions. The primary outcome was total antibiotic prescribing rate. There were 16 secondary prescribing outcomes and 5 hospital admission outcomes (potential adverse effects of reduced prescribing). The main evaluation timepoint was 1 year after the final report (Quarter 1, 2018), with an additional evaluation in the quarter after the final report (Quarter 2, 2017). Routine administrative NHS data were used to generate the feedback reports and analyse the effects. Results Total antibiotic prescribing rates were lower at the main evaluation timepoint in both intervention (1.83 versus baseline 1.93 prescriptions/1000 patients/day) and control (1.90 versus baseline 1.98) practices, with no evidence of intervention effect [adjusted rate ratio (ARR) 0.98 (95% CI 0.94–1.02; P = 0.35)]. At the additional timepoint, adjusted total antibiotic prescribing rates were 1.67 and 1.73 prescriptions/1000 patients/day, with evidence of a small intervention effect, ARR 0.99 (0.98–1.00; P = 0.03). Conclusions This well-designed, practice-level antibiotic-prescribing feedback had limited evidence of additional effects in the context of decreasing antibiotic prescribing and an established national stewardship programme.

Background Reducing antibiotic use is central to antimicrobial stewardship, but may have unintended consequences. Objectives To examine associations between size of decline in antibiotic prescriptions in general practices and (i) rate of hospitalization for infection and (ii) patient satisfaction. Methods Routine data analysis for all general practices in Scotland, quarter one 2012 (Q1 2012) to quarter one 2018 (Q1 2018). Practices were grouped into quartiles of rate of change in prescribing and changes in rates of hospitalization were compared across groups. For satisfaction analysis, associations between practice-level patient satisfaction in 2017–18 (Scottish Health and Care Experience Survey) and prior change in antibiotic prescription were examined. Results Antibiotic prescriptions overall fell from 194.1 prescriptions/1000 patients in Q1 2012 to 165.3 in Q1 2018 (14.9% reduction). The first quartile of practices had a non-significant increase in prescriptions [change per quarter = 0.22 (95% CI −0.42 to 0.86) prescriptions/1000 patients], compared with large reductions in the other three groups, largest in quartile four: −2.95 (95% CI −3.66 to −2.24) prescriptions/1000 patients/quarter (29.7% reduction overall). In all quartiles, hospitalizations with infection increased. The increase was smallest in quartile four (the biggest reduction in prescriptions) and highest in quartile one (no significant change in prescriptions): 2.18 (95% CI 1.18 to 3.19) versus 3.68 (95% CI 2.64 to 4.73) admissions/100 000 patients/quarter, respectively [difference = − 1.50 (95% CI −2.91 to −0.10)]. There was no statistically significant association between change in antibiotic prescriptions and patient satisfaction. Conclusions Very large reductions in antibiotic prescriptions in Scottish general practices have not been associated with increases in hospitalization with infection or changes in patient satisfaction.