Community Interventions

The possibility to change antibiotic prescription behavior patterns using specific training on rational use of antibiotics as target group interventions is one of the options that have shown an impact in a short period of time. Several interventions have targeted both physicians and general public to increase awareness of the adequate use of antimicrobial drugs.

Perez-Cuevas et al. conducted an educational intervention in 18 primary care facilities in Mexico City to improve prescribing practices for rhinopharyngitis. Using a workshop and a managerial peer review committee, the authors documented a decrease in the percentage of patients receiving antibiotics from 85.2 to 48%; the physicians' inappropriate use of antibiotics went from 70%

(baseline) to 42.3% immediately after the intervention, and 45.8% at the 18-month follow-up (Perez-Cuevas et al. 1992).

Two major things can be learnt from this study: first, that almost 80% of the physicians were using inappropriate antibiotics for rhinopharyngitis and that, after the intense intervention, antibiotic use decreased significantly; however, almost 50% of these physicians maintained their behavior to use them; second, it is evident that the intervention must be sustained for longer periods of time to be able to change prescription behavior patterns.

In Mexico, Gutierrez et al. (1994) used an intervention strategy designed to decrease drug prescription in the treatment of acute diarrhea aimed at family medicine practitioners. The authors evaluated 20 physicians who received the complete intervention (study group) and 20 physicians who received none (control group). The treatment behaviors of the study and control groups were similar on baseline but differed significantly in the post-workshop evaluation. The study group showed a reduction in the use of antibiotics (from 78.8 to 39.3%) for children younger than 5 years old with acute diarrhea. In the midterm evaluation, the use of antibiotics by the study group decreased to 27.6%. In the long-term evaluation, persistent positive prescribing behavior was still present in the study group, with a significant difference compared to the control group, where no modification was found in the prescribing behavior throughout the study.

In a similar study conducted in Indonesia, Santoso et al. (1996) investigated the impacts of two different methods of educational intervention, i.e., a small-group face-to-face intervention and a formal seminar for prescribers, on prescribing practice in acute diarrhea. The results showed that both interventions were equally effective in improving the levels of knowledge of prescribers about the appropriate management of acute diarrhea. They were also partially effective in improving the appropriate use of drugs, reducing the use of non-rehydration medications. There was a highly significant reduction of antimicrobial usage after either small-group face-to-face intervention or formal seminar, and the former caused significantly greater reduction than the latter. The authors concluded that the small-group face-to-face intervention is as effective as, and less costly than, the seminar, making it a feasible option for improving antimicrobial prescribing patterns in developing countries.

Bexell et al. (1996) explored the impact of continuing education seminars on the quality of patient management and rational drug use in Zambia. In the intervention health centers, the average number of drugs per patient decreased from 2.3 to 1.9 (p = 0.005) and the proportion of patients managed with nonpharmacological treatment increased from 1 to 13.2%. More drugs were correctly chosen in the intervention health centers compared to control health centers. The proportion of patients prescribed antibiotics decreased and the proportion of patients adequately managed increased in the intervention health centers.

Hennessy et al. (2002) were able to diminish the antibiotic prescription rate in Alaskan rural villages by 35% after an appropriate use of antibiotics education program focused on both the community and the physicians. Rubin et al. (2005)

conducted a multifaceted intervention to improve antimicrobial prescribing for upper respiratory tract infections (URTIs) in a small rural community in Utah. The intervention involved patient education materials, a media campaign to increase public awareness, small group sessions involving physicians, and physician use of URTI algorithms. After 6 months, the percentage of patients in the community who received antibiotics for URTIs during the intervention period was 15.6% less than that for the baseline period. There was a decrease of 56% on antibiotic prescriptions for acute bronchitis and a 13.4% decrease on macro-lides prescriptions. Among hospitalized patients, there was no significant decrease in the number of patients with URTI who were prescribed an antibiotic, although there was also a decrease in macrolide use (11.2%).

In Australia, Dollman et al. (2005) conducted a community-based intervention to reduce antibiotic use for upper respiratory tract infections. These investigators used consumer information on antibiotic use for URTIs (including a local media campaign) and education of health professionals (including sessions with general practitioners at the four practices in the study area). After 4 months of intervention, the prescription rates for the six most common antibiotics prescribed for URTI (amoxicillin, amoxicillin/clavulanic acid, cefaclor, doxycycline, erythromycin, and roxithromycin) decreased by 32%. These kinds of interventions have been able to reduce the number of prescription of certain types of antibiotics.

In the United States, during the 1992-2000 period, there was a reduction in the prescription rates of amoxicillin-clavulanic acid, cephalosporins, and ery-thromycin, but an increase was noted in macrolides, such as azithromycin and clarithromycin, and fluoroquinolones. In patients under 15 years of age, there was an increase of 69% in the prescription of amoxicillin-clavulanic acid (McCaig et al. 2003). In Manitoba, Canada, a decrease of almost 30% in antibiotic prescriptions was estimated in the 1996-2000 period, but the rate of broad-spectrum macrolide prescriptions increased 12-fold in the same period (Kozyrskyj et al. 2004).

As shown by the data above, a decrease in the prescription rates of some antimicrobial drugs has been accompanied by an increase in others, usually with a broader spectrum, which has a negative impact on the antimicrobial resistance phenomenon.

A large-scale multinational intervention, the Integrated Management of Childhood Illness (IMCI), was developed by WHO and UNICEF to provide effective and affordable interventions to reduce child mortality and improve child health and development. Gouws et al. (2004) assessed the effect of IMCI case management training on the use of antimicrobial drugs among health-care workers treating young children at first-level facilities in Brazil, Uganda, and Tanzania. Overall, children seen by IMCI-trained, health-care workers were less likely to receive unnecessary antibiotics in all three countries and more likely to receive correct prescriptions for antimicrobial drugs when needed. Caregivers whose children were seen by workers not trained in IMCI received little or no information about how to administer antibiotics.

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