Bundle of Interventions Reduces Inappropriate Antibiotics for Upper Respiratory Tract Infection

A 4-component intervention bundle was found effective in reducing inappropriate antibiotic prescribing for outpatients presenting with upper respiratory tract symptoms, in a prospective, cluster randomized trial¹ conducted at several health centers in Qatar.

"Multidimensional interventions which include components addressing predisposing, reinforcing, and enabling factors have been shown to be more successful than single interventions in various settings," explained Adeel Butt, MBBS, MS, Corporate Quality and Patient Safety Department, Hamad Medical Corporation, Doha, Qatar, and colleagues.

Recognizing that acute upper respiratory tract infections (URTI) in outpatients are highly likely to be treated with antibiotics despite studies showing that most are of viral origin, Butt and colleagues sought to establish guidelines for appropriate prescribing and interventions to increase awareness of, and adherence to them.Their trial to measure the effectiveness of the interventions was conducted in 4 health centers, with 2 randomly designated for the intervention and 2 to serve as controls.

Standards for appropriate antibiotic prescribing for URTI were drawn from existing professional society guidelines.The interventions to encourage adherence to the guidelines, developed by experts in infectious diseases, family practice and pediatrics, were pilot-tested on a group of physicians who were not affiliated with the study sites.Their feedback was incorporated into the final materials.

The 4-component intervention bundle comprised:

• Extensive provider education
• An algorithm-driven decision support tool
• Option for providing deferred prescription

(ie, to be filled and taken if symptoms persisted beyond 72 hours)

• Monthly feedback on prescription patterns

(including anonymized peer comparison)

The education component included an overview of the study aims and logistics, given at all 4 sites; and, for the 2 intervention sites, presentations on appropriate use of antibiotics for common URTIs.The algorithm on management of URTIs was provided in a print format to physicians of the intervention sites at the initial training session, and in monthly email reminders. The option to provide a deferred antibiotic prescription was reserved for patients at low risk of bacterial infection, and when a physician indicated the likelihood of initiating an antibiotic if there was no option for a deferred prescription.

The feedback on prescribing patterns, provided on a customized dashboard for each physician at the intervention sites, included the number of antibiotics prescribed by that physician and the number of prescriptions deemed inappropriate based on the diagnostic codes that they had assigned; as well as anonymized monthly data of total and inappropriate prescriptions for all other physicians at that site.

Butt and colleagues analyzed over 20,000 episodes of care for URTIs during the period from December 2023 to October 2024; with 9,277 antibiotic prescriptions at control sites and 10,785 at intervention sites.They reported the intervention was associated with 29% reduction in odds of inappropriate antibiotic prescriptions (aOR 0.71 [95% CI 0.66-0.77]). The relative reduction was 20.9% (44.9% vs 35.5%) between the two groups; and the relative drop in inappropriate antibiotic prescriptions before and after the intervention was 16.3% (42.4% vs 35.5%).

Interestingly, the investigators noted higher odds of inappropriate antibiotic prescribing among senior physicians compared with those in training. "Possible explanations of this important observation include long-standing habits, lower likelihood of attending continuing education programs, and reliance on personal anecdotal experiences rather than evidence-based guidelines by the senior physicians," they posited.

Reference

1. Butt AA, Shams S, Jabeen A, et al. A prospective cluster randomized trial of an intervention bundle to reduce inappropriate antibiotic use for upper respiratory tract infections in the outpatient setting. BMC Infect Dis 2025; 25:818. https://doi.org/10.1186/s12879-025-11210-z.