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Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme

Lars Bjerrum12*, Anders Munck2, Bente Gahrn-Hansen2, Malene Plejdrup Hansen2, Dorte Ejg Jarbol2, Gloria Cordoba2, Carl Llor3, Josep Maria Cots3, Silvia Hernández3, Beatriz González López-Valcárcel4, Antonia Pérez4, Lidia Caballero5, Walter von der Heyde5, Ruta Radzeviciene6, Arnoldas Jurgutis6, Anatoliy Reutskiy7, Elena Egorova7, Eva Lena Strandberg8, Ingvar Ovhed8, Sigvard Mölstad8, Robert Vander Stichele9, Ria Benko9, Vera Vlahovic-Palcevski9, Christos Lionis10 and Marit Rønning11

Author Affiliations

1 Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark

2 Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark

3 Spanish Society of Family Medicine, Barcelona, Spain

4 University of Las Palmas, Gran Canarias, Las Palmas, Spain

5 Misiones Association of General Family Medicine, Posadas, Argentina

6 Public Health Department, Faculty of Health Sciences, Klaipeda University, Lithuania

7 Association of Family Doctors, Kaliningrad, Russia

8 Department of Clinical Sciences, Lund University, Malmoe, Sweden

9 European Drug Utilisation Research Group, Ghent, Belgium

10 World Organisation of Family Doctors (WONCA) Europe, Ljubljana, Slovenia

11 World Health Organisation, Collaborating Centre for Drug Statistics Methodology, Oslo, Norway

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BMC Family Practice 2011, 12:52  doi:10.1186/1471-2296-12-52

Published: 20 June 2011



Excessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance.


GPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention.


A total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%.


A multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.