Systematic Reviews

For Healthcare Professionals

Below is a collection of systematic reviews that have examined the most effective interventions to improve antibiotic prescribing for outpatients.

Systematic Reviews
Reference Interventions and Outcomes Methods, Participants, and Settings Results Conclusions
Arnold SR, et al. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev 2005. 4:CD003539. InterventionsPhysician educational materials

Audit and feedback

Educational meetings

Educational outreach visits

Financial and healthcare system changes

Physician reminders

Patient-based interventions

Multi-faceted interventions


Improve selection, dose and duration of antibiotics prescribed

Reduce incidence of pathogens with antimicrobial resistance

MethodsSystematic review


Healthcare consumers or primary care providers


Primary care clinics and ambulatory care clinics

39 studies

Only small changes observed for single interventions using printed educational materials or audit and feedback.

Active educational interventions are more effective than nonactive interventions.

Delayed prescriptions effectively reduced antibiotic use by patients without negatively affecting patient outcomes.

Multifaceted interventions were more successful in decreasing inappropriate antibiotic prescribing.

Multifaceted interventions are most effective.

No single intervention is recommended for all settings.

Drekonja DM et al. Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol 2015. Feb;36(2):142–52.


InterventionsProvider and or patient education

Provider feedback

Delayed prescribing

Communication skills training


Restriction Policies

Computerized clinical decision support

Financial incentives

Rapid diagnostics

Costs reporting


Prescribing outcomes

Patient outcomes

Microbial outcomes



MethodsSystematic review


Primarily healthcare consumers and primary care providers


Primary care clinics and ambulatory care clinics


50 studies

Stewardship programs using communication skills training and laboratory testing can lower antibiotic use.

Several stewardship interventions can effectively improve antibiotic prescribing.

Patient outcomes were not often reported, but did not appear to worsen due to intervention.

Outpatient antibiotic stewardship programs can improve antibiotic prescribing without negatively affecting patient outcomes.

Sustainability and scalability of specific interventions is less clear.

McDonagh M, et al. Improving Antibiotic Prescribing for Uncomplicated Acute Respiratory Tract Infections. AHRQ Comparative Effectiveness Reviews 2016. No. 163.






Multifaceted interventions


Improvement of appropriate antibiotic prescribing

Reduction in antibiotic resistance

Reduction in overall antibiotic prescribing for acute respiratory tract infections (RTIs)

Increases in adverse drug events

Increases in patient dissatisfaction

MethodsSystematic review


Healthcare consumers (both adults and children) with acute RTIs

Primary care providers


Primary care clinics and ambulatory care clinics


133 studies

Four interventions showed evidence of improving antibiotic prescribing with without worsening patient outcomes due to reductions in antibiotic prescribing:

Clinic-based parent education (21% reduction).

Public patient education campaigns combined with clinician education (7% prescribing reduction).

Procalcitonin for adults (12% to 72% prescribing reduction).

Electronic decision support systems (improved antibiotic selection and 5% to 9% reduction in prescribing).

Public parent education campaigns reduce overall prescribing without increasing followup visits.

Several interventions safely reduced antibiotic prescribing or improved appropriate antibiotic prescribing without adversely affecting patient outcomes.

These include education for patients, parents, and clinicians, procalcitonin testing in adults, and electronic clinician decision support.


Ranji SR, et al. Interventions to reduce unnecessary antibiotic prescribing: A systematic review and quantitative analysis. Med Care 2008. 46(8):847–62. InterventionsClinician education

Patient education

Audit and feedback

Clinician reminders


Reduction in proportion of patients receiving antibiotics

MethodsSystematic review and quantitative analysis


Healthcare consumers (both adults and children) with acute outpatient infections

Primary care providers


Primary care clinics and ambulatory care clinics

43 studies

Most studies examined antibiotic prescribing for acute respiratory infections.

The quantitative analysis (n = 30 studies) found a median reduction of 9.7% in the percent of patients receiving antibiotics

No single intervention was clearly superior.

Active clinician education strategies had a nonsignificant trend toward better efficacy compared with passive education strategies.

Some interventions are effective at reducing antibiotic use in outpatient settings.

Active clinician education strategies appear to work better than passive education strategies.

Targeting antibiotic prescribing for all ARIs, versus single diagnoses, may lead to larger reductions in antibiotic use.

van der Velden AW, et al. Effectiveness of physician-targeted interventions to improve antibiotic use for respiratory tract infections. Br J of Gen Pract 2012. 62(605):e801–7.


InterventionsEducational materials (patients, clinicians, and the general public)

Educational meetings

Consensus procedure

Local opinion leaders

Near-patient testing

Audit and feedback

Financial incentives

Communications skills training


Difference of differences for interventions with a before and after measurement with a control group

Differences for interventions with a before and after measurement without a control group

Difference in after measurement for interventions with a control group but without a before measurement

MethodsSystematic review


Healthcare consumers (both adults and children) with acute outpatient infections

Primary care providers


Primary care clinics in high income countries


58 studies

About 60% of studies contained interventions that led to significant improvements in antibiotic prescribing.

Interventions targeting decreases in overall antibiotic prescription were more often effective than interventions targeting improvements in antibiotic selection.

Antibiotic prescriptions were reduced on average by 11.6%. First-line antibiotic prescription increased on average by 9.6%.

Combination interventions targeting clinicians were more often effective compared with single interventions.

Interventions containing patient-directed materials demonstrated no added value.

Interventions with the largest effect sizes included communication skills training and point-of-care testing.

Clinician education, including communication skills training, is important to optimize antibiotic use.

Combination interventions appear to be more effective than individual interventions.


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