The limited number of published articles on antibiotic campaigns and the difficulties in obtaining unpublished quantitative data meant we were unable to do a formal systematic review. However, a systematic search strategy was used and data were retrieved according to a standardised form. Campaigns were identified by searches of PubMed, the internet by use of Google, manual searches of reference lists from relevant articles, and contact with experts in the field—namely CHAMP collaborators,
ReviewCharacteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries
Introduction
Resistance to antimicrobial drugs is an increasing threat to public health. The reasons for the increase in antimicrobial resistance are complex, but it has become evident that excessive use of antibiotics is linked to the emergence and selection of resistance.1, 2 In high-income countries the majority of antibiotics for use in human beings are prescribed in the ambulatory-care setting for upper respiratory tract infections; a substantial proportion of these prescriptions are unnecessary.3, 4, 5, 6, 7
There are several methods for promoting careful use of antibiotics focusing on prescribers, the public, or both, but the most effective approach is unknown.8, 9 The prescription of antibiotics is influenced by a complex interplay between the knowledge, attitude, and behaviour of the prescribing physician and the patient.10 In several studies, patients expecting an antibiotic prescription—or patients whose physician anticipates such an expectation—are more likely to be prescribed one.11, 12, 13, 14, 15
There have been various attempts to educate the public about appropriate use of antibiotics. Several clinical trials at the community level, mostly done in the USA, have shown at least moderate benefits of patient education on the use of antibiotics.16, 17, 18, 19, 20 In several countries, public campaigns have been done on a larger scale.21 In Europe, numerous new national campaigns were launched on the occasion of the first European Antibiotic Awareness Day on Nov 18, 2008.22
A paper by Roger G Finch and colleagues23 published in The Lancet Infectious Diseases several years ago summarised the findings of an international workshop on educational interventions to improve the use of antibiotics, and it included a review of the characteristics of four public campaigns. By use of a systematic approach we try to give more comprehensive and updated information about the characteristics and outcomes of large-scale public campaigns in high-income countries with the aim of improving the use of antibiotics.
Section snippets
Geographic distribution
Applying our search and selection criteria, we were able to identify 22 campaigns (table 1).16 campaigns were done on a national and six on a regional level. In the USA, the CDC's Get Smart programme is mostly done at the state level and comprises more than 30 different regional campaigns (table 1 includes a selection of the more intense state-wide campaigns), which we grouped into one national campaign for this analysis, since most of these campaigns were based on the CDC's Get Smart framework
Organisation
In most cases, the decision to launch campaigns on the appropriate prescription of antibiotics was made by health authorities. In at least four European countries, campaigns were planned as part of a national strategy to reduce resistance to antimicrobial drugs. These strategies also included measures to promote appropriate use of antimicrobial drugs in hospitals, long-term care facilities, and the agricultural sector (Belgium, England and Northern Ireland [UK], France, and Norway). Health
Interventions used in the campaigns
Some components of the campaigns targeted mainly the public (ie, using mass distribution of information intended for the so-called lay public), while others targeted health-care professionals (ie, information directly addressed to the health-care professional, such as letters or guidelines). However, this distinction is not clear-cut, since there is substantial overlap between these categories (health-care professionals might also be influenced by the public education component, whereas some of
Outcomes
To identify the effect and the most effective interventions, campaigns have to be evaluated (panel 1). This is a weak point of numerous campaigns, partly explained by insufficient funding and difficulty in obtaining data. Several campaigns have not been evaluated and the scope and quality of evaluation of the remaining campaigns varied greatly.
Potential adverse effects of reduced prescribing
There is some concern that reduced use of antibiotics leads to an increase in complications resulting from the progression of infections that would have benefited from antibiotics. Unfortunately, possible indicators for the underprescribing of antibiotics were not monitored during the campaigns. A retrospective analysis of the campaign in the French Alpes-Maritimes region did not show an increase in the incidence of invasive infections due to S pneumoniae, Haemophilus influenzae, Streptococcus
Cost-benefit analysis
It is not surprising that a decrease in antibiotic prescriptions is associated with a decrease in pharmacy expenditures. In New Zealand, there was a decrease in national antibiotic expenditures from NZ$36 million to $14·5 million between 1996 and 2003. One third of the decrease is explained by a reduction in prescribing, which in turn might be because of the national campaign ongoing since 1999, with a budget of $100 000–170 000 per year.34 The remaining two thirds can be attributed to a
Limitations
There are several limitations to this Review. First, we included only campaigns in high-income countries. We believe that this restriction is justified, since many issues related to health care such as the cause of respiratory tract infections, rates of complications in patients, availability of health care, and over-the-counter availability of antibiotics vary between high and low-to-middle income countries. Legislation changes might be a more efficient first step in reducing the use of
Conclusions
There have been numerous campaigns to promote appropriate use of antibiotics in high-income countries, varying from simple, low-cost internet campaigns to expensive mass-media campaigns. Although hard scientific evidence for a cause–effect relation is lacking, the results of several campaigns suggest they had a positive effect on the use of antibiotics. From the available data, it seems that multifaceted campaigns repeated over several years have the greatest effect. It is, however, unclear to
Search strategy and selection criteria
References (132)
- et al.
Antibiotic prescribing rates in the US ambulatory care setting for patients diagnosed with influenza, 1997–2001
Respir Med
(2004) - et al.
Educational interventions to improve antibiotic use in the community: report from the International Forum on Antibiotic Resistance (IFAR) colloquium, 2002
Lancet Infect Dis
(2004) - et al.
“Antibiotics only when necessary” campaign in the Alpes-Maritimes district: no negative impact on invasive infections in children in the community 1998–2003
Presse Med
(2008) - et al.
The “Antibiotics only when necessary©” campaign and its implementation in the French Alpes-Maritimes subdivision
Med Mal Infect
(2003) - et al.
Peer visits to community-based general practitioners and pediatricians as part of the “Antibiotics only when necessary” campaign in the Alpes-Maritimes district: methodology, feasibility, and interest
Presse Med
(2006) - et al.
Type of child care and nasopharyngeal S pneumoniae and H influenzae carriage in children in the Alpes-Maritimes
Presse Med
(2004) - et al.
Communication and diet: an overview of experience and principles
J Nutr Educ Behav
(2007) - et al.
Patterns of antibiotic use among adults and parents in the community: a questionnaire-based survey in a Greek urban population
Int J Antimicrob Agents
(2005) - et al.
Over-the-counter acquisition of antibiotics in the Maltese general population
Int J Antimicrob Agents
(2002) Reducing antibiotic use in influenza: challenges and rewards
Clin Microbiol Infect
(2008)
Injudicious antibiotic use: an unforeseen consequence of the emphasis on patient satisfaction?
Clin Ther
Antimicrobial prescribing for upper respiratory infections and its effect on return visits
Fam Med
Antimicrobial use and antimicrobial resistance: a population perspective
Emerg Infect Dis
Antimicrobial resistance determinants and future control
Emerg Infect Dis
Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians
JAMA
Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis
JAMA
Excessive antibiotic use for acute respiratory infections in the United States
Clin Infect Dis
Analysis of under- and overprescribing of antibiotics in acute otitis media in general practice
J Antimicrob Chemother
Interventions to improve antibiotic prescribing practices in ambulatory care
Cochrane Database Syst Rev
Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis
Med Care
Strategies for promoting judicious use of antibiotics by doctors and patients
BMJ
Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations—a questionnaire study
BMJ
Influence of patients' expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study
BMJ
Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats
BMJ
Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription
J Fam Pract
Ruling out the need for antibiotics: are we sending the right message?
Arch Pediatr Adolesc Med
A community intervention trial to promote judicious antibiotic use and reduce penicillin-resistant Streptococcus pneumoniae carriage in children
Pediatrics
Changes in antibiotic prescribing for children after a community-wide campaign
JAMA
Changes in antibiotic-prescribing practices and carriage of penicillin-resistant Streptococcus pneumoniae: a controlled intervention trial in rural Alaska
Clin Infect Dis
“Get smart Colorado”: impact of a mass media campaign to improve community antibiotic use
Med Care
Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts
Pediatrics
National campaigns to improve antibiotic use
Eur J Clin Pharmacol
European Antibiotic Awareness Day, 2008—the first Europe-wide public information campaign on prudent antibiotic use: methods and survey of activities in participating countries
Euro Surveill
Evaluation of a national programme to reduce inappropriate use of antibiotics for upper respiratory tract infections: effects on consumer awareness, beliefs, attitudes and behaviour in Australia
Health Promot Int
An ongoing national programme to reduce antibiotic prescription and use
Microbiol Australia
Association between antibiotic sales and public campaigns for their appropriate use
JAMA
Achievements of the Belgian Antibiotic Policy Coordination Committee (BAPCOC)
Euro Surveill
2006 National Report Card on Antibiotic Resistance
Significant reduction of antibiotic use in the community after a nationwide campaign in France, 2002–2007
PLoS Med
Modification of prescribers' behavior: the Icelandic approach
Clin Microbiol Infect
The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance
Proc Natl Acad Sci USA
Can a nationwide media campaign affect antibiotic use?
Am J Manag Care
Public views and use of antibiotics for the common cold before and after an education campaign in New Zealand
NZ Med J
Antibiotic use for upper respiratory tract infections before and after a education campaign as reported by general practitioners in New Zealand
NZ Med J
Trends in nasopharyngeal carriage of Streptococcus pneumoniae among children attending daycare centers in southeastern France from 1999 to 2006
Pediatr Infect Dis J
Did local enhancement of a national campaign to reduce high antibiotic prescribing affect public attitudes and prescribing rates?
Eur J Gen Pract
Don't wear me out—the public's knowledge of and attitudes to antibiotic use
J Antimicrob Chemother
The public's attitudes to and compliance with antibiotics
J Antimicrob Chemother
Can mass media campaigns change antimicrobial prescribing? A regional evaluation study
J Antimicrob Chemother
Impact of statewide program to promote appropriate antimicrobial drug use
Emerg Infect Dis
Cited by (340)
Global trend of antimicrobial resistance in common bacterial pathogens in response to antibiotic consumption
2023, Journal of Hazardous MaterialsParents’ awareness of antimicrobial resistance: a qualitative study utilising the Health Belief Model in Perth, Western Australia
2022, Australian and New Zealand Journal of Public HealthMicrobiological analysis and antibiotic selection strategy in neck abscesses among patients with diabetes mellitus
2024, European Archives of Oto-Rhino-LaryngologyTrends in antibiotic prescribing in primary care out-of-hours doctors’ services in Ireland
2024, JAC-Antimicrobial Resistance