Review
Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries

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Summary

The worldwide increase in resistance to antimicrobial drugs has made reducing the unnecessary use of antibiotics a public health priority. There have been campaigns in many countries to educate the public about appropriate use of antibiotics in outpatients. By use of a comprehensive search strategy and structured interviews, we were able to identify and review the characteristics and outcomes of 22 campaigns done at a national or regional level in high-income countries between 1990 and 2007. The intensity of the campaigns varied widely, from simple internet to expensive mass-media campaigns. All but one campaign targeted the public and physicians simultaneously. Most campaigns that were formally evaluated seemed to reduce antibiotic use. The effect on resistance to antimicrobial drugs cannot be assessed accurately at present. Although the most effective interventions and potential adverse outcomes remain unclear, public campaigns can probably contribute to more careful use of antibiotics in outpatients, at least in high-prescribing 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

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,

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