Effects of primary care antimicrobial stewardship outreach on antibiotic use by general practice staff: pragmatic randomized controlled trial of the TARGET antibiotics workshop

Abstract

ObjectivesTo determine whether local trainer-led TARGET antibiotic interactive workshops improve antibiotic dispensing in general practice.MethodsUsing a McNulty–Zelen-design randomized controlled trial within three regions of England, 152 general practices were stratified by clinical commissioning group, antibiotic dispensing rate and practice patient list size, then randomly allocated to intervention (offered TARGET workshop that incorporated a presentation, reflection on antibiotic data, promotion of patient and general practice (GP) staff resources, clinical scenarios and action planning, 73 practices) or control (usual practice, 79 practices). The primary outcome measure was total oral antibiotic items dispensed/1000 patients for the year after the workshop (or pseudo-workshop date for controls), adjusted for the previous year’s dispensing.ResultsThirty-six (51%) intervention practices (166 GPs, 51 nurses and 101 other staff) accepted a TARGET workshop invitation. In the ITT analysis total antibiotic dispensing was 2.7% lower in intervention practices (95% CI −5.5% to 1%, P = 0.06) compared with controls. Dispensing in intervention practices was 4.4% lower for amoxicillin/ampicillin (95% CI 0.6%–8%, P = 0.02); 5.6% lower for trimethoprim (95% CI 0.7%–10.2%, P = 0.03); and a non-significant 7.1% higher for nitrofurantoin (95% CI −0.03 to 15%, P = 0.06). The Complier Average Causal Effect (CACE) analysis, which estimates impact in those that comply with assigned intervention, indicated 6.1% (95% CI 0.2%–11.7%, P = 0.04) lower total antibiotic dispensing in intervention practices and 11% (95% CI 1.6%–19.5%, P = 0.02) lower trimethoprim dispensing.ConclusionsThis study within usual service provision found that TARGET antibiotic workshops can help improve antibiotic use, and therefore should be considered as part of any national antimicrobial stewardship initiatives. Additional local facilitation will be needed to encourage all general practices to participate.

How Can National Antimicrobial Stewardship Interventions in Primary Care Be Improved? A Stakeholder Consultation

“…Improving engagement with AMS training and resources: There are many AMS interventions available, including AMS training and resources tested and shown effective in trials [21,25,27]. For example, the TARGET antibiotic toolkit (with training and resources primarily targeted at GPs) is available online [29] and practice workshops promoting the TARGET resources were shown effective [27]. Similarly, the STAR online communication skills training (with a practice seminar) was shown effective in a trial [25] and is now available online on the clinical professional development website [30].…”

“…Yes [21,25,27] Yes (e.g., TARGET [29], STAR [30])-but: online only, targeted mainly at prescribers, varied uptake/engagement…”

“…(1) Standardized quality improvement with tailored advice and action planning, [8,[20][21][22][23][24][26][27][28] were identified and are reported elsewhere [11]. 2 Twenty six nationally implemented AMS interventions were identified previously and are reported elsewhere [10].…”

“…Twenty-two interventions for primary care prescribers and eight for community pharmacy staff were identified, targeting on average 5.8 HCPs' behaviors [10]. A follow-up study identified barriers and facilitators to appropriate antibiotic prescribing in primary care and found nine interventions evaluated in the UK and shown effective at reducing antibiotic prescribing [11]; these included five research-only interventions [20][21][22][23][24] and four nationally available interventions: communication skills training [25], FeverPAIN clinical score [26], the TARGET toolkit [27], and the Chief Medical Officer's letters with prescribing feedback to the highest-prescribing practices [28]. Analyzing the behavioral content of the identified AMS interventions and comparing the extent to which they address relevant behaviors and key barriers and facilitators led to identification of potential changes to, or gaps to be addressed by, AMS interventions.…”

Progress in the long battle against antimicrobial resistance

“…The RCGP's Treat Antibiotics Responsibly, Guidance, Education, Tools (TARGET) toolkit is the primary initiative to support GPs and other health professionals to reduce antibiotic prescribing in the community. 5 There is evidence that it is effective 6,7 but ESPAUR notes that CCGs need to do more to promote it and to be more focused on action. All but 1% of CCGs promote TARGET to their GPs and its web page is the most visited on the RCGP website; the number of hits recorded in 2018 was about the same as in previous years.…”