A simple behavioral “nudge” helped primary care clinicians significantly reduce inappropriate antibiotic prescriptions for acute respiratory infections, according to researchers.

The intervention, a poster committing a clinician to appropriate antibiotic use displayed in the exam room, resulted in a 9.1 percentage-point drop in inappropriate prescriptions for acute respiratory infections, Daniella Meeker, PhD, of the RAND Corp. in Santa Monica, Calif., and colleagues reported in JAMA Internal Medicine.

After controlling for baseline antibiotic prescribing rates the benefits were even greater, with the poster intervention resulting in a nearly 20 percentage-point reduction (P=0.02).

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Antimicrobial resistance is a growing concern, but many interventions to reduce prescribing rates described in the literature are evidence-based and rational. The model from Meeker and colleagues relies on the assumption that clinicians are influenced by other social factors, including perceived demand from patients, the desire to conform with peers and “the need to act in ways that are consistent with one’s previous public commitments.”

So they assigned clinicians from five primary care clinics in the Los Angeles areas to sign and display a poster-sized commitment  letter in exam rooms for 12 weeks or to practice as normal. The posters were written at an eighth grade reading level in both English and Spanish.

The year-long study involved 14 clinicians — 11 doctors and three nurse practitioners — who treated 954 adult patients with visits for acute respiratory infections. Overall, 449 patients were treated by clinicians in the intervention group, including 335 in a 40-week baseline period and 114 during the 12-week intervention period. The remaining 505 patients were assigned to the control group, including 384 during baseline and 121 during the intervention.

Inappropriate antibiotic prescribing rates were similar in both the control and intervention groups during the baseline period (43.5% and 42.8%, respectively).

During the intervention, inappropriate antibiotic prescriptions decreased to 33.7% in the poster group, but increased to 52.7% in the control group.

In an accompanying editorial, Brad Spellberg, MD, of Harbor–UCLA Medical Center in Los Angeles, Calif., called the study results “modest” but “significant,” noting that the intervention was easy to implement and “required no complex algorithms, no special technology and no infrastructure or enforcement.”

“Meeker et al have created a Judo-like approach that works with patient and clinician psychology to reduce antibiotic prescriptions,” Spellberg wrote. “Meaningful gains can be achieved with minimal effort and cost.”

Study limitations include the small geographic range and study sample size and a relatively short duration of observation, the researchers noted.


  1. Meeker D et al. JAMA Intern Med. 2014; doi: 10.1001/jamainternmed.2013.14191.
  2. Spellberg B. JAMA Intern Med. 2014; doi:10.1001/jamainternmed.2013.14019.