The “Minimizing Antibiotic Resistance in Colorado” Project: Impact of Patient Education in Improving Antibiotic Use in Private Office Practices

Multiple organizations have called for decreases in excess antibiotic use in ambulatory practice as an important component of strategies to combat antimicrobial resistance in the United States (Jernigan, Cetron, and Breiman 1996). This public health imperative is driven by two key observations from the past decade: (1) antibiotic resistance among community-acquired bacterial pathogens (e.g., Streptococcus pneumoniae, Staphylococcus aureus, and Escherichia coli) is rising rapidly (Herold et al. 1998; Chen et al.1999; Gupta, Scholes, and Stamm 1999; Whitney et al. 2000; Hyde et al. 2001); and (2) recent antibiotic use is one of the strongest risk factors for carriage or infection with resistant bacteria (Nava et al. 1994; Hofmann et al. 1995; Arnold et al. 1996; Nuorti et al. 1998). Strategies to reduce inappropriate prescribing of antibiotics in the ambulatory setting must focus on the management of acute respiratory tract infections (ARIs), which resulted in 76 million visits to office-based physician practices in the U.S. during 2000 (Source: National Ambulatory Medical Care Survey, public use datafiles). These infections account for the vast majority of ambulatory antibiotic prescriptions in the U.S. (McCaig and Hughes 1995). Yet, many of these prescriptions likely provided little clinical benefit since the overwhelming majority of ARIs have a viral etiology; particularly colds, unspecified upper respiratory tract infections, and acute bronchitis (Gonzales et al. 1997). It appears that physicians and the public are beginning to heed the call to limit the over-use of antibiotics for ARIs in U.S. office-based practices. Between 1990 and 2000, the proportion of children with ARIs treated with antibiotics decreased by 14 percent (McCaig, Besser, and Hughes 2002). While this secular trend is promising, greater reductions are needed, since it has been estimated that over 50 percent of antibiotic prescriptions for ARIs are not necessary (Gonzales et al. 2001b). A number of controlled studies in the U.S. have confirmed the benefit of combined patient and physician educational interventions in reducing antibiotic use for ARIs beyond that attributable to secular trends (Gonzales et al. 1999; Belongia et al. 2001; Finkelstein et al. 2001; Perz et al. 2002). To date, however, there have been no community-based intervention trials, aimed at reducing excess antibiotic use, that have targeted adults in traditional fee-for-service, private office practices. The present study was designed to assess the impact of adding patient education to an existing physician-centered intervention directed at reducing antibiotic prescribing for children with pharyngitis and adults with acute bronchitis. In the first phase of the Minimizing Antibiotic Resistance in Colorado Project, we designed and launched this trial of a household- and office-based patient education intervention, known as the “Be S.M.A.R.T. about Antibiotics” campaign (S.M.A.R.T.=Strategies for Minimizing Antibiotic Resistance Together) in November 2001. The major hypothesis was that a combined patient and physician intervention would be more effective than a physician-centered intervention alone in reducing excess antibiotic use in private office practices.