Antibiotics are one of the most widely used drugs in the world. The utilization rate of antibiotics is an important indicator to judge whether medical staff use drugs appropriately. The misuse of antibiotics will not only damage the health of patients, but also cause a huge waste of medical resources26. Therefore, while maintaining policy continuity, the health sector should further regulate the use of antibiotics in medical institutions, improve medical facilities and equipment, optimize the overall medical level, and curb the misuse of antibiotics at the source. At the same time, it is also necessary to improve training and education policies for medical personnel, encourage doctors to learn more relevant theoretical knowledge, improve the level of medical technology, and strengthen the understanding of the use of antibiotics in order to reduce the rate of misuse of antibiotics. Medical institutions should provide more lectures on the health knowledge of the harms of antibiotic misuse and publicize the harms of antibiotic misuse and other relevant knowledge, so that patients and their families can also deepen their understanding of antibiotics, strictly follow the doctor's advice for medication, and reduce the amount of antibiotics used by themselves. It is hoped that through our research, some effective measures for antibiotic prescription control will be proposed to future researchers.
This study systematically evaluated the intervention measures of antibiotic prescription rates and their implementation effect in 9 relevant studies. The meta-analysis results showed that the antibiotic prescribing rate of the pre-group antibiotic intervention was significantly lower than that of the control group (RD = -0.12, 95% CI = -0.16, -0.07, P < 0.01). Results of the meta-analysis showed a high degree of heterogeneity (I² = 99%), thus the results could not be combined, Therefore, subgroup analyses were conducted to explore the reasons for the heterogeneity. Although subgroup analysis showed that heterogeneity could be partially eliminated by grouping at different levels, many studies still showed high heterogeneity. This suggests that interventions may also have more complex implicit influencing factors or interactions.
From the subgroup analysis by study area, the impact of the intervention was greatest in Asian countries, with a significant reduction in antibiotic prescription rates. Qiu25 and Wei27 used a similar multivariate feedback intervention (Table 2) while the European studies were highly heterogeneous. Among them, the study of Dyrkorn from Norway (RD = 0.00, 95% CI = -0.06, 0.05) showed that the effect of the intervention on antibiotic prescription rates was not significant23. That study recruited physicians to conduct a peer education program on antibiotic prescribing for respiratory infections. The program consisted of three 45 minute interactive educational sessions for the intervention group to learn national guidelines. Compared to the control group, the intervention group followed the national guidelines more, the antibiotic utilization rate of penicillin V increased and the utilization rate of macrolides decreased, but there was no significant difference in the total antibiotic prescription rate between the intervention group and the control group. The other study was conducted by Ferrat E21 in France. Due to the large sample size, we conducted a sensitivity analysis on the two articles from Europe (I2 was reduced from 99–0%). Both of these articles adopted on-site intervention measures, so we divided the 9 sudies into the two subgroups: whether or not they used on-site interventions.
From the subgroup analysis by intervention mode, the reduction of antibiotic prescription rates in studies using off-site interventions was significantly greater than that among studies using in-site interventions. This may be explained by the short intervention duration implemented in the two studies by Dyrkorn23 and Ferrat21 (1 day and 2 days respectively), although the duration of data collection was 2 years and 4 months, and 4 years and 6 months, respectively. Although the effects of the intervention were significant, whether these effects were caused by the intervention would be difficult to determine. The Llor19 study also found little or no effect on prescribing behavior over a short period of time for physicians to provide antibiotic education materials, prescription audits, and prescription recommendations. Therefore, the effect of single or short-term intervention on doctors was limited, and long-term and diversified interventions were needed to effectively reduce the prescription rates of antibiotics.
The effect of interventions in which doctors were given prescription recommendations by peer experts was better than not those in which doctors were not given prescription recommendations, and the reduction in antibiotic prescribing rates was statistically significant for this subgroup.
In summary, multiple feedback interventions were used in most of the included studies. Therefore, the hospitals should strengthen the education and training related to antibiotic prescribing behaviors of doctors, and organize medical staff to delve deep into the rules and regulations of antibiotics, and make full use of pharmacology, pharmacokinetics, pharmacodynamics, and other relevant knowledge to issue prescriptions28,29. On this basis, various feedback interventions can be added, such as communication between experts and peers, prescription audits, and ranking of doctors in the same department. In addition, interventions can improve the awareness of patients and their families toward antibiotics, such as providing them with brochures and leaflets, displaying posters in the waiting rooms, installing a multimedia education system in wating areas, and encouraging patients to communicate more with their physicians about the use of antibiotics. Dekker17, Llor19, and Metlay22 adopted certain intervention measures for patients and their families based on educational intervention measures for medical staff. Altiner18 intervened patients and their families based on using feedback intervention for medical staff, and the degree of reduction of antibiotic utilization was significantly higher than other studies. Therefore, according to education and training interventions, feedback interventions were used to influence the prescribing behavior of doctors and improve the cognition of patients and their families about antibiotics. This multivariate behavioral feedback intervention might be a more rational approach to antibiotic prescription control. In terms of policymaking, health administration departments should introduce laws, regulations, and relevant policies on the administration of antibiotics to strictly control the use of antibiotics. These departments can take strong administrative interventions against the unreasonable use of antibiotics, for example, patients or consumers could only obtain antibiotics from the pharmacies based on prescriptions, and doctors can prescribe antibiotics in a hierarchical manner.
Our study has certain limitations. First, only nine studies could be included, therefore there is a possibility of publication bias. However, some studies were not included due to incomplete data. Thislimitations may have reduced the objectivity of the results to a certain extent. Second, there are different degrees of quality differences in the design of the included studies, which may have affected our results. Third, the nine studies were conducted in 7 countries. The policies and management systems of antibiotic use are different among countries, thus there was a risk of information bias. Lastly, there was still a high degree of heterogeneity of some data in the subgroup analyses indicating that there were still other unknown factors affecting the results.