(230) A pragmatic randomized trial assessing the impact of peer comparison and therapeutic recommendations on antibiotic prescribing patterns of family physicians for uncomplicated lower urinary tract infections

Background: Urinary tract infections (UTIs) are one of the most common bacterial infections managed in primary care. Inappropriate antibiotic prescribing practices have contributed to the rise of antimicrobial resistance. Audit and feedback interventions are a proven strategy to address regional knowledge gaps and support clinician behavioural change.

Objectives: To evaluate the impact of personalized prescribing Portraits and brief evidence summaries (Therapeutics Letters) on empiric treatment of uncomplicated lower urinary tract infections (UTI) by Family Physicians (FPs).

Methods: We conducted a cluster randomized control trial in British Columbia, Canada between September 23, 2021 and March 28, 2022. We randomized 5 073 FPs into an early Portrait and Therapeutics Letter intervention arm (n=1 691), a Portrait-only arm (n=1 691), and a delayed control arm (n=1 691). The Portrait contained personalized and peer-comparison data on first-line antibiotic prescriptions for women with uncomplicated lower UTI and key therapeutic recommendations. The Therapeutics Letter (TL) contained detailed evidence-based UTI management recommendations, incorporating regional antibiotic resistance data, and recommended nitrofurantoin as first-line treatment. The main outcome was first-line nitrofurantoin treatment for uncomplicated lower UTI, analysed using an intention-to-treat approach. The trial protocol was registered with ClinicalTrials.gov (NCT05817253).

Results: We identified 21,307 cases of uncomplicated lower UTI among the three trial arms during the study period. The impact of receiving both the Portrait and TL increased the relative probability of prescribing nitrofurantoin as first-line treatment for uncomplicated lower UTI by 28% (OR 1.28; 95% CI 1.07 – 1.52), relative to the control arm. This translates to prescribing of nitrofurantoin as first-line treatment, instead of alternates, in an additional 8.7 cases of uncomplicated UTI per 100 FPs during the 6-month study period.

Conclusions: Feedback of personal prescribing data to FPs with peer comparison, accompanied with evidence-based therapeutic recommendations, can significantly improve evidence-concordant prescribing of antibiotics for uncomplicated lower UTI.