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Academic Detailing to Improve Use of Broad-Spectrum Antibiotics at an Academic Medical Center
Daniel H. Solomon, MD, MPH;
Laura Van Houten, BA;
Robert J. Glynn, PhD, ScD;
Lindsey Baden, MD;
Kelley Curtis, RPh, MBA;
Harry Schrager, MD;
Jerry Avorn, MD
Arch Intern Med. 2001;161:1897-1902.
ABSTRACT
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Background Antibiotic misuse is common and costly and may promote antibiotic resistance.
We tested the efficacy of a targeted one-on-one educational program ("academic
detailing") designed to improve the appropriateness of broad-spectrum antibiotic
use.
Methods A randomized controlled trial was conducted in a large US teaching hospital.
During an 18-week study period, 17 general medical, oncology, and cardiology
services either received academic detailing or did not. The intervention was
prompted by an order for either levofloxacin or ceftazidime that led to a
computer-based review of data for that patient. Orders for the 2 target antibiotics
deemed unnecessary by a priori criteria were included in the study. The primary
outcome examined was the number of days that unnecessary levofloxacin or ceftazidime
was administered in intervention and control groups.
Results Before the trial, intervention and control services had similar prescribing
patterns for the target antibiotics; the drugs were used for similar indications
throughout the study period. During the intervention, there was a reduction
of 37% in days of unnecessary levofloxacin or ceftazidime use per 2-week interval
on services randomized to the educational intervention vs control services
(P<.001). In multivariable analyses controlling
for baseline prescribing and study interval, the rate of unnecessary use of
the 2 target antibiotics was reduced by 41% on the intervention services compared
with controls (95% confidence interval, 44%-78%; P<.001).
Length of stay, intensive care unit transfers, readmission rates, and in-hospital
death rates were similar in both groups (P .10
for all).
Conclusion Targeted one-on-one education is a practical, effective, and safe method
for reducing excessive broad-spectrum antibiotic use.
INTRODUCTION
ANTIBIOTIC MISUSE is common and costly. Approximately one third of all
hospitalized patients receive an antibiotic, and several reports1-3
suggest that at least half of antibiotic orders are unnecessary, poorly chosen,
or incorrectly dosed. Physicians often opt for broad-spectrum antibiotics
when a narrower-spectrum agent would suffice. A review of 2 months of vancomycin
hydrochloride use at one teaching hospital found that 70% of orders were inappropriate;
problematic orders were as common for the medical service as they were for
the surgery service.1
Suboptimal use of antibiotics poses problems beyond those applicable
to the individual patient so treated; overreliance on broad-spectrum agents
is also thought to be an important contributor to growing worldwide antimicrobial
resistance.4 A recent study5
found that as quinolone use increased more than 6-fold between 1988 and 1997,
from 0.8 to 5.5 per 100 persons per year, the prevalence of pneumococci with
reduced susceptibility to quinolones increased from 0% to 1.7%. Quinolone-resistant Salmonella enterica and Campylobacter
jejuni infections have also been increasingly reported.6-7
New antimicrobial resistance has emerged in many different human pathogens,
and rates of existing resistance have increased. At least 6 studies8-13
have suggested that rates of invasive infections with drug-resistant Streptococcus pneumoniae are related to recent antibiotic
exposure, and 1 recent study14 suggested that
local antibiotic use patterns directly affected local resistance patterns.
These data have prompted a working group of the Centers for Disease Control
and Prevention to focus attention on the judicious use of antibiotics as one
part of the strategy to combat drug-resistant Streptococcus
pneumoniae.15 Although antimicrobial
resistance is complex and multifactorial, there is evidence that reducing
the use of broad-spectrum antibiotics may result in improved microbial susceptibility.16
In most hospitals, antibiotics account for more than 10% of pharmacy
expenditures, and the additional cost of antibiotic resistance is substantial.
A report from the US Office of Technology Assessment estimated that the extra
hospital costs associated with drug-resistant nosocomial bacterial infections
were $1.3 billion annually.17 In our institution,
drug use evaluations have suggested that narrower-spectrum antibiotics could
be safely substituted for a substantial number of broad-spectrum antibiotic
orders. However, most patients are never seen by infectious disease consultants;
thus, there is no routine method for such antibiotic optimization. Given increasing
concern over unnecessary patient exposure to broad-spectrum antibiotics, trends
in antimicrobial resistance patterns, and the costs associated with both,
we undertook the present study to determine whether one-on-one education by
clinical specialists on a patient-specific basis ("academic detailing") could
reduce excessive use of broad-spectrum antibiotics.
PARTICIPANTS AND METHODS
STUDY SITE
Brigham and Women's Hospital is a 697-bed academic medical center affiliated
with Harvard Medical School in Boston, Mass. Approximately 32% of admissions
are to the internal medicine department, including general medical, oncology,
and cardiology services. A typical service consists of 1 attending physician,
1 second- or third-year medical resident, and 2 interns; interns and residents
write all antibiotic orders.
To achieve balanced patient groups for the present study, we assigned
services to intervention or control status using a blocked randomization design.
Three of the general medical services were randomly assigned to intervention
and 3 to control, and 2 of the oncology services were randomly assigned to
intervention and 2 to control. Three additional general medical services and
4 cardiology services were added at week 5 through a similar blocked random
assignment approach. In all, 9 services comprised the intervention group and
8 the control group. The study period began January 20, 1999, and ended May
19, 1999; the 4 weeks immediately preceding this period were considered the
baseline period.
TARGET ORDERS
We used the hospital's computerized pharmacy records to review all orders
for levofloxacin and ceftazidime written for patients on the intervention
and control teams. The hospital's Division of Infectious Diseases developed
a set of guidelines for first-line antibiotic therapy, including recommendations
for the proper use of these agents. We disseminated these guidelines to all
house officers as pocket-sized laminated brochures (available on request)
before this study. Although in any given situation many antibiotics may be
effective, these guidelines recommended preferred antibiotic choices for our
hospital.
Each morning, a research assistant reviewed computerized laboratory,
pharmacy, and prior admission data for all patients for whom physicians ordered
levofloxacin or ceftazidime in the prior 24 hours. The criteria were applied
without regard to the study group assignment. All orders for levofloxacin
were flagged for review unless the patient had (1) an isolate sensitive to
levofloxacin, (2) a history of a solid organ transplantation or long-term
use of immunosuppressive medications, (3) multiple antibiotic allergies, or
(4) serum creatinine levels of more than 1.5 mg/dL (132.6 µmol/L). For
ceftazidime, orders were also flagged unless the patient had (1) an isolate
sensitive to ceftazidime; (2) an absolute neutrophil count of less than 500/mm3; (3) a history of a solid organ transplantation, cystic fibrosis,
or long-term use of immunosuppressive medications; (4) multiple antibiotic
allergies; or (5) resided in an institutional setting within 1 week of hospital
admission. Henceforth, we will use the term unnecessary
use for the orders that fell outside the guidelines and were flagged
for review. We excluded orders for patients in whom any of the following occurred
on the date their target order was reviewed: death, discharge, transfer to
an intensive care unit, or surgery. The remaining orders formed the study
cohort. On the intervention services, levofloxacin or ceftazidime orders judged
to be unnecessary prompted one of the academic detailers to review the patient's
full medical record and contact the responsible intern or resident. No contact
occurred for orders written for patients on teams randomized to the control
condition.
INTERVENTION
The educational intervention was directed at interns and residents on
the intervention teams who wrote unnecessary orders for either of the 2 broad-spectrum
antibiotics studied. The educational intervention, which used an academic
detailing approach, was conducted by 3 clinician-educators, 2 infectious diseases
physicians, and 1 specially trained clinical pharmacist.18-19
The educators were trained through participating in practice sessions, with
several of the authors (D.H.S. and J.A.) using scripts and role-playing exercises.
The intern who wrote the original order was the primary contact, but
resident physicians were contacted if the intern was unavailable. Academic
detailers presented information to the intern or resident physicians interactively
in a case-relevant, concise manner, stressing microbiologic data, local resistance
patterns, and the clinical literature. The interns and residents were not
aware that their ordering patterns were being studied. The detailers provided
each ordering physician with a copy of the guidelines and made suggestions
for alternative regimens based on these recommendations, but the final drug
choice was always left to the interns and residents. The clinician-educators
also distributed graphs and summaries of resistance patterns in our institution
and trends in the utilization and cost of antibiotics (available on request).
The encounter took place over the telephone if neither intern nor resident
was available to meet in person; this occurred in 32 episodes. In 4 instances,
the responsible intern or resident was unavailable to meet or speak by telephone;
e-mail messages were sent to the interns in these cases. All encounters were
included in the intervention group. Face-to-face or telephone sessions generally
lasted 10 minutes. In 14 instances, the academic detailer decided not to contact
either intern or resident after reviewing the chart. This was primarily because
prior infectious disease consultants had recommended one of the targeted antibiotics.
These orders were included in all analyses.
DATA COLLECTION
The main study end point was the average number of days that unnecessary
levofloxacin or ceftazidime was administered per service. This outcome was
compared for each 2-week interval for services in the intervention vs control
groups. The prescribing information was drawn from the hospital's computerized
pharmacy records. In a subsample of patients, we validated the computerized
pharmacy data against the manually completed medication administration records
in the patient's hospital chart. There was complete agreement in 14 (93%)
of 15 patient records examined and partial agreement in the 1 remaining record.
Patients who were prescribed more than one new course of levofloxacin or ceftazidime
were counted in the analysis more than once. We also reviewed the medical
records of all patients in both the intervention and control groups to determine
the presumed source of infection that prompted the target antibiotic order.
Next, medication orders for the day of the educational intervention (or the
comparable day on the control services) were examined to determine whether
the target drug regimens were continued, discontinued, or changed in route
or dosage. Finally, we examined computerized records for every patient admitted
to intervention or control services during the study period to measure rates
of death and transfer to an intensive care unit, length of stay, and readmission
within 30 days of discharge.
ANALYSIS
We compared the average number of days of unnecessary levofloxacin and
ceftazidime use during each 2-week interval for the intervention and control
services. To calculate the expected values and confidence intervals (CIs)
and to test differences, we used a linear univariate fixed-effects model (PROC
MIXED).20 Since we suspected that differences
in baseline prescribing and duration of the intervention would be important
confounders, multivariable models were constructed including these factors
as independent variables. The dependent variable was unnecessary prescribing
of the target antibiotics during each 2-week interval of the intervention
period. To estimate the relative reduction in unnecessary use of target antibiotics
in the intervention group, we used a fixed-effects model (PROC GENMOD in SAS
statistical software).20 This model used a
log-linear link function, assumed a Poisson distribution, and accounted for
overdispersion. Experimental group assignment (intervention or control) was
the independent variable of interest, the individual service was considered
a class effect, and covariates included level of baseline prescribing and
time, modeled as both a linear and categorical effect. The interaction between
assignment and time was also assessed. We further considered a linear random-effects
model to account for variation between services (PROC MIXED in SAS statistical
software)20; the results of this analysis were
similar to those found in the fixed-effects models with respect to the level
of statistical significance, and only the fixed-effects model results are
presented.
All analyses were conducted on an intention-to-treat basis. Several
services had unusually heavy prescribing of the target antibiotics during
certain 2-week blocks. To examine the effect of such periods, we performed
identical analyses of the main effect after removing these outlier intervals
from the analyses. The results were nearly identical; thus, only the analyses
using all data points will be presented. Finally, we assessed the mean length
of stay for all patients on intervention and control services and measured
the proportion of patients who were transferred to an intensive care unit,
were readmitted to Brigham and Women's Hospital within 30 days of discharge,
or died in the hospital. We examined these secondary outcomes not only for
patients who received the target antibiotics, but also for every patient admitted
to a study service during the baseline and intervention periods.
RESULTS
More than 4500 patients were admitted to the intervention and control
services during the baseline and study periods. Patient characteristics on
both sets of services were similar and did not differ between the baseline
and study periods (Table 1). At
baseline, the mean ± SD number of days of unnecessary target antibiotic
use was 8.5 ± 7.8 per 2-week interval for the intervention service
and 7.6 ± 4.7 for the control services (P
= .80) (Figure 1).
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Table 1. Characteristics of Study Services*
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Figure 1. Average number of days of unnecessary
use of target antibiotics per 2-week interval per service. P<.001 for the difference between intervention and control groups
during the study period. For the study period, confidence intervals were calculated
from the univariate fixed-effects model. See text for description of "unnecessary
use of target antibiotics."
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During the 18-week study period, 490 patients from all study services
were prescribed levofloxacin or ceftazidime, the target antibiotics. Computerized
record review indicated that 212 patients were not appropriate for study for
the following reasons: 83 were discharged, transferred to an intensive care
unit, taken to surgery on the index date, or died; 37 had serum creatinine
levels greater than 1.5 mg/dL (>132.6 µmol/L); 23 had a known isolate
sensitive to one of the target antibiotics; 21 had a history of a solid organ
transplantation or were taking immunosuppressive medications; 20 who were
prescribed ceftazidime had an absolute neutrophil count less than 500/mm3; 18 had multiple antibiotic allergies; and 10 who were prescribed
ceftazidime had cystic fibrosis and were at high risk of pseudomonal infections.
The remaining 278 unnecessary prescriptions in 260 patients formed the study
cohort. Among these patients, the indications for treatment or presumed sources
of infection were similar for those in the intervention and control groups
(Table 2). There were slightly
higher rates of fever and neutropenia among levofloxacin users on the intervention
services (P = .04).
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Table 2. Presumed Source of Infection During Study Period*
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We then examined the mean number of days of unnecessary target antibiotic
use per 2-week interval per service for each group (Figure 1). Although baseline prescribing was similar, during the
intervention period, the number of days of unnecessary use of target antibiotics
was 37% lower for the intervention services than for controls (P<.001) (Figure 1). During
the study period, there were a mean ± SD of 5.5 ± 2.1 days per
2-week interval for the intervention services vs 8.8 ± 2.2 days for
the controls; this reduction was because of 28 fewer starts and an average
antibiotic course 0.8 day shorter. The multivariate analyses, accounting for
repeated measures of the target antibiotics and baseline prescribing, indicated
that the risk of receiving a day of unnecessary target antibiotic was reduced
by 41% on the intervention services compared with controls (95% CI, 44%-78%; P<.001). There did appear to be an effect of time on
the intervention, such that the risk of prescribing an unnecessary day of
the target antibiotics continued to decline throughout the entire study period.
However, no interaction was found between group assignment and time (P = .48). During the study period, prescribing of the target
antibiotics throughout the hospital on nonstudy services remained stable:
1874 days of target antibiotics administered per 2-week interval during the
baseline period vs 1882 days during the intervention period (P = .40).
We next examined prescribing of unnecessary target antibiotics on the
day that the order was identified and the subsequent day (Figure 2). For the intervention services, 88 (70%) of these orders
were discontinued, whereas only 46 orders (30%) for the control services were
discontinued (P = .001). For the intervention services,
69 patient orders (55%) for unnecessary target antibiotics had all antibiotic
use discontinued. This significantly differed from the control services in
which only 24 patient orders (16%) were followed by discontinuation of all
antibiotic use (P = .001). Route changes (intravenous
to oral) were equal and uncommon (14%) for both intervention and control services.
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Figure 2. Antibiotic prescribing during
intervention. The day the target order was identified and the next calendar
day were examined to determine these patterns. P
values are from  2 tests and refer to the difference between
intervention and control groups.
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The intervention had no measurable negative clinical effects. The average
length of stay, proportion of patients transferred to an intensive care unit
or patients readmitted within 30 days of discharge, and death rates were similar
for all patients in the intervention and control services (Table 3).
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Table 3. Secondary Outcomes
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COMMENT
Reduction of inappropriate use of antibiotics, especially broad-spectrum
agents, is an important goal in acute care settings such as teaching hospitals.
In a randomized controlled trial that took place in the department of medicine
of a US academic medical center, we found that the risk of prescribing a day
of unnecessary target antibiotic was 41% lower on services randomized to a
intervention of "academic detailing" compared with controls. This significant
effect of the intervention remained after adjusting for baseline prescribing,
clustering of repeated measures within a given service, and duration of the
intervention. Both fewer starts and shorter courses of target antibiotics
account for the reduction of use of broad-spectrum antibiotics in the intervention
services. This suggests that to some degree interns and residents learned
not to prescribe an unnecessary antibiotic but that the daily academic detailing
reminded prescribing physicians to stop the use of previously started but
unnecessary antibiotics.
The intervention was based on the academic detailing approach developed
by our group that has proven to be a useful method for improving behavior
in a variety of prescribing situations.18-22
Academic detailing is a program of one-on-one interactive educational outreach
provided by a clinician, either a pharmacist or physician, who has been trained
to discuss prescribing decisions with physicians in a manner likely to induce
evidence-based practice change. An academic detailing approach has been used
successfully to improve outpatient antibiotic use, but not inpatient prescribing,
to our knowledge.18, 23-24
Several limitations of the present study should be considered. Since
resident physicians switched services every month, contamination occurred
between intervention and control groups. This would have biased the results
against finding any difference between intervention and control teams and
thus may have dampened the observed effect of the intervention. One method
for dealing with this potential would have been to randomize physicians; however,
many of the decisions regarding antibiotic orders are made by the team and
thus randomization by a physician would have allowed for substantial intrateam
contamination. Fourteen orders were included in the intervention set that
were not deemed appropriate for academic detailing because the antibiotics
had been suggested by a prior consultation from the infectious diseases division.
We kept these orders in the analysis since they were part of the original
randomization set; their inclusion reduced the effect of the intervention.
Finally, although we did not collect specific data from house officers about
why they continued using possibly unnecessary antibiotics, possible reasons
include misinformation, neglect of microbiologic laboratory information, pressure
from attending physicians, and patient or family concerns.25
Part of the success or failure of the academic detailing intervention
rests on the ability and availability of the educators doing the one-on-one
intervention. We attempted to minimize the effect of the detailer's personal
style on the study outcome by standardizing the educational encounter through
the use of scripts and a common evidence-based approach. In addition, many
hospitals may not have infectious disease consultants available to perform
the academic detailing. Our intervention used a trained clinical pharmacist
whose impact on prescribing was similar to that of the infectious disease
physicians; previous interventions have likewise used pharmacist-educators
with good effects.18, 21
Other than the one-time initial costs of developing and printing antibiotic
guidelines for our hospital, the daily costs of conducting the intervention
included approximately 1 hour of a research assistant's time to review new
orders for the target antibiotics and 1 hour from an academic detailer; thus,
the estimated annual cost was $21 750. Although a formal economic analysis
was not performed, we found that the length of antibiotic courses was shortened
on the services randomized to the intervention: 55% of patients had all antibiotic
use stopped in the 24 hours after the intervention vs 16% in the controls.
In addition, there is a real but hard-to-quantify economic benefit of reducing
the risk of resistance associated with overuse of broad-spectrum antibiotics.
Taken together, these benefits are likely to outweigh the very modest cost
of the intervention. As a result, we plan to continue and expand such antibiotic
counterdetailing efforts in our institution.
Further work will be required to demonstrate the generalizability of
an academic detailing approach to other settings and to define the most efficient
means to conduct such programs on a larger operational scale. Although development
of newer antibiotics may help address antimicrobial resistance in the short
term, improving the prescribing of available antibiotics will continue to
be a priority throughout the health care system for the foreseeable future.
AUTHOR INFORMATION
Accepted for publication February 22, 2001.
Financial support for this work was provided by a core grant from the
Brigham and Women's Hospital to the Division of Pharmacoepidemiology and Pharmacoeconomics.
Dr Solomon is a recipient of an Arthritis Foundation Investigator Award.
Gonzalo Graupera, MD, and Asra Warsi provided assistance with data collection
and Nancy Keating, MD, MPH, provided helpful comments on an early draft of
the manuscript.
Corresponding author and reprints: Daniel H. Solomon, MD, MPH, Division
of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital,
221 Longwood Ave, Suite 341, Boston, MA 02115 (e-mail: dhsolomon{at}partners.org).
From the Divisions of Pharmacoepidemiology and Pharmacoeconomics (Drs
Solomon, Glynn, and Avorn and Mss Van Houten and Curtis) and Infectious Diseases
(Drs Baden and Schrager), Department of Medicine, Brigham and Women's Hospital,
Harvard Medical School, Boston, Mass.
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