INNOVATION FUND The Future of Academic Medicine Quality Improvement & Outcomes SHOWCASE 2023

The development and testing of a scaling strategy for a community-based primary care antimicrobial stewardship program utilizing an innovative University of Toronto primary care testing platform: The UTOPIAN practice based research network

Quality Improvement & Outcomes

Warren McIsaac



SH-UHN AMO; Sinai Health, Mount Sinai Hospital, University of Toronto

Andrew Morris


This project demonstrated a scalable way to assist family physicians and other primary care providers (nurse practitioners, pharmacists) to more judiciously prescribe antibiotics for common infections occurring in the community. Achieving this outcome is critical to limiting further increases in antibiotic-resistant infections in Ontario and Canada.
With the supports tested in this project, this project could be adopted in other family medicine clinics and pharmacies across Ontario.
The outcome achieved in this project was a 22% reduction in overall antibiotic use. Currently, the project has not been implemented more broadly, such that these outcomes have not yet been realized system wide. The testing of this strategy in multiple community-based family medicine clinics during the routine provision of clinical care supports the feasibility and practicality of the proposed approach.


Objectives: With the relationship between total antibiotics prescribed and resistance levels, and that 90% of prescriptions occur in the community, this project aimed to demonstrate a reduction in unnecessary antibiotic prescriptions in busy primary care clinics, through a practical and feasible program of community antibiotic stewardship.
Methodology: A program of practical strategies most likely to be feasible in busy primary care clinics was developed and tested in 6 large family medicine clinics using a pragmatic randomized clinical trial design. Ongoing support was provided to 3 clinics, both logistically and in-kind, to foster program implementation, with 3 additional clinics acting as control sites not receiving the program. The number of antibiotics prescribed, types and their duration, as well as any adverse effects, were tracked over one season.
Results: There were 1682 encounters involving 54 primary care providers followed from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22%. The odds that a delay in filling a prescription was recommended was increased more than 2-fold, while prescription durations greater than 7 days were reduced 76%. Optimal antibiotic choices, as
recommended by experts, were prescribed similarly in control (85.4%) and intervention clinics (91.8%). No increase in hospital or emergency department visits occurred.
Conclusions: This community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of any antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations.
Challenges Faced: The available budget and 2-year duration limited the number of test clinics that could be recruited and the impact that could be demonstrated.
Next steps: Funding for a larger scale study will be sought to demonstrate the value of a province-wide program.


McIsaac WJ, Kukan S, Huszti E, Szadowski L, O’Neill B, Virani S, Ivers N, Lall R, Toor N, Shah M, Alvi R, Bhatt A, Nakamachi Y, Morris AM. A pragmatic controlled trial of a primary care antimicrobial stewardship program in Ontario, Canada BMC Fam Pract 2021;185.

McIsaac WJ, Senthinathan A, Moineddin R, Nakamachi Y, Dresser L, McIntyre M, Singh S, De Oliveira N, Tannenbaum D, Bloom J, Lemieux C. Development and evaluation of a primary care antimicrobial stewardship program (PC-ASP) in Toronto, Ontario, Canada. JAMMI. 2021 Mar;6(1):32-48.
Jeffs L, McIsaac WJ, Zahradnik M, Senthinathan M, Dresser L, McIntyre M, Tannenbaum DW, Bell CM, Morris A. Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: a qualitative study. PLOS One 2020; 15(3): e0223822.​

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