Abstract: Thirty-nine studies examined the effect of printed educational materials for physicians, audit and feedback, educational meetings, educational outreach visits, financial and healthcare system changes, physician reminders, patient-based interventions and multi-faceted interventions. These interventions addressed the overuse of antibiotics for viral infections, the choice of antibiotic for bacterial infections such as streptococcal pharyngitis and urinary tract infection, and the duration of use of antibiotics for conditions such as acute otitis media. Use of printed educational materials or audit and feedback alone resulted in no or only small changes in prescribing. The exception was a study documenting a sustained reduction in macrolide use in Finland following the publication of a warning against their use for group A streptococcal infections. Interactive educational meetings appeared to be more effective than didactic lectures. Educational outreach visits and physician reminders produced mixed results. Patient-based interventions, particularly the use of delayed prescriptions for infections for which antibiotics were not immediately indicated effectively reduced antibiotic use by patients and did not result in excess morbidity. Multi-faceted interventions combining physician, patient and public education in a variety of venues and formats were the most successful in reducing antibiotic prescribing for inappropriate indications. Only one of four studies demonstrated a sustained reduction in the incidence of antibiotic-resistant bacteria associated with the intervention. The effectiveness of an intervention on antibiotic prescribing depends to a large degree on the particular prescribing behaviour and the barriers to change in the particular community. No single intervention can be recommended for all behaviours in any setting. Multi-faceted interventions where educational interventions occur on many levels may be successfully applied to communities after addressing local barriers to change. These were the only interventions with effect sizes of sufficient magnitude to potentially reduce the incidence of antibiotic-resistant bacteria. Future research should focus on which elements of these interventions are the most effective. In addition, patient-based interventions and physician reminders show promise and innovative methods such as these deserve further study.

Plain-language summary: Research has shown that physicians in the community (in doctors' offices and clinics) can be partly to blame for resistant bacteria. Studies have shown that physicians inappropriately prescribe antibiotics for infections caused by viruses (such as the common cold). They also prescribe antibiotics that kill a wide variety of bacteria when an antibiotic that kills specific bacteria should be prescribed. Physicians may also prescribe the wrong dose for the wrong length of time. Inappropriate prescribing is due to many factors including patients who insist on antibiotics, physicians who do not have enough time to explain why antibiotics are not necessary and therefore simply prescribe them to save time, physicians who do not know when to prescribe antibiotics or how to recognise a serious bacterial infection, or physicians who are overly cautious. To improve how physicians prescribe antibiotics in the community, methods have been studied. In this review, 39 studies were analysed to determine what works. Using printed materials to educate physicians about prescribing or to give them feedback about how they prescribed did not improve their prescribing or only improved it by a small amount. Meetings to educate physicians improved their prescribing but lectures did not. It was not clear whether personal visits to the physicians by educators worked or not or whether reminders to physicians worked or not . The use of delayed prescriptions decreased use of antibiotics without increasing the risk of serious illness. A delayed prescription means the physician gives a patient a prescription for an antibiotic a few days after the doctor visit; it is thought that if the infection is not serious it will clear up on its own over that time and the patient does not need the antibiotics. The studies also found that using many methods together, such as the ones above, worked better than using one method alone. Since there are many reasons why physicians in the community prescribe antibiotics inappropriately, one method cannot be recommended. But using many methods to change prescribing may be successful.