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Research and Projects

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT) - a realist review

Who is involved?

Theme: CLAHRC - Evidence for Policy and Practice
Status: Live


“A post-antibiotic era—in which common infections and minor injuries can kill—far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century”

Dr Keiji Fukuda, World Health Organisation (WHO) Assistant Director-General.

Anti-Microbial Resistance (AMR) is the ability of microorganisms that cause disease to withstand attack by antimicrobial medicines. AMR is also costly, estimated at US$21-34 billion dollars per annum in the USA. The consequences extend beyond patients who present with infections. Many surgical procedures (where antibiotics are given prophylactically in the hope of preventing infections) may be harder to justify as the risk and consequences of infection become more likely and serious.

There are two important strands of activity to address this global crisis. The first is to develop new antimicrobials, the second is to urge all countries to be more prudent in their use of antimicrobials - this is the focus of our proposed research. Antimicrobial stewardship aims to promote optimal care for patients with infections, whilst minimising the public health threat of drug resistance. However, changing prescribing behaviour is difficult and the challenge is significant given that less than 50% of antibiotic usage in hospitals is inappropriate.

The development of antimicrobial resistance has been described as a global crisis - more prudent prescribing is part of the solution. Behaviour change interventions are urgently needed to improve prescribing practice. Presently, the literature documents that context impacts on prescribing decisions. Yet minimal tailoring of interventions by context or grade of prescriber, makes it hard for researchers and policy makers to draw firm conclusions or make recommendations about ‘what works’, ‘for whom’, ‘in what circumstances’, ‘how’ and ‘why’ in their context. Doctors in training are an important group to study, being numerically the largest group of prescribers in UK hospitals. Unfortunately very few interventions have specifically targeted this group.

Review questions

  1. What are the mechanisms by which antimicrobial prescribing behaviour change interventions are believed to result in their intended outcomes?
  2. What are the important contexts which determine whether the different mechanisms produce intended outcomes?
  3. In what circumstances are such interventions likely to be effective?

Project aims and objectives

To understand how interventions to change antimicrobial prescribing behaviours of doctors in training produce their effects.


  1. To conduct a realist review to understand how interventions to change antimicrobial prescribing behaviours of doctors in training produce their effects.
  2. To provide recommendations on tailoring, implementation and design strategies to improve antimicrobial prescribing behaviour change interventions for doctors in training.

Anticipated outputs

The project will produce three major types of outputs:

  1. The findings from the review will be submitted for publication to a high-impact peer-reviewed journal. We anticipate that such a publication is most likely to impact at an academic level - informing the understanding and theoretical basis of antimicrobial prescribing behaviour change interventions.
  2. A ‘How to’ publication that outlines practical advice to optimise, tailor and implement existing interventions designed to change prescribing behaviour in doctors in training. With this publication we aim to impact the day to day antimicrobial prescribing practice of doctors in training. This document is mainly targeted at Audience 2: Clinical supervisors/trainers and medical educators.
  3. User-friendly summaries of the review’ findings that are tailored to the needs of the following audiences:
  • Doctors in training
  • Clinical supervisors/trainers and medical educators
  • Policy, decision makers, regulators and Royal Societies

Funding details

This project was funded by NIHR HS&DR (12/97/24)

Further information

For more information, view the protocol.

View poster to be presented at the Global Implementation Conference, Toronto, June 2017 - "Improving antimicrobial prescribing of doctors-in-training: Does realist review give insight into systemic implementation issues?"

Others Involved

Karen Mattick


University of Oxford
Geoff Wong
Chrysanthi Papoutsi

University of Plymouth
Nicola Brennan