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Feasibility and effectiveness of a low cost campaign on antibiotic prescribing in Italy: community level, controlled, non-randomised trial

BMJ 2013; 347 doi: (Published 12 September 2013) Cite this as: BMJ 2013;347:f5391
  1. Giulio Formoso, epidemiologist,
  2. Barbara Paltrinieri, scientific journalist,
  3. Anna Maria Marata, clinical pharmacologist,
  4. Carlo Gagliotti, epidemiologist,
  5. Angelo Pan, infectivologist,
  6. Maria Luisa Moro, head of infective risk area,
  7. Oreste Capelli, pneumologist,
  8. Nicola Magrini, head of drug evaluation area
  9. for the LOCAAL Study Group
  1. 1Emilia-Romagna Regional Agency for Health and Social Care, Viale Aldo Moro 21, 40127 Bologna, Italy
  1. Correspondence to: G Formoso gformoso{at}
  • Accepted 16 August 2013


Objectives To test the hypothesis that a multifaceted, local public campaign could be feasible and influence antibiotic prescribing for outpatients.

Design Community level, controlled, non-randomised trial.

Setting Provinces of Modena and Parma in Emilia-Romagna, northern Italy, November 2011 to February 2012.

Population 1 150 000 residents of Modena and Parma (intervention group) and 3 250 000 residents in provinces in the same region but where no campaign had been implemented (control group).

Interventions Campaign materials (mainly posters, brochures, and advertisements on local media, plus a newsletter on local antibiotic resistance targeted at doctors and pharmacists). General practitioners and paediatricians in the intervention area participated in designing the campaign messages.

Main outcomes measures Primary outcome was the average change in prescribing rates of antibiotics for outpatient in five months, measured as defined daily doses per 1000 inhabitants/day, using health districts as the unit of analysis.

Results Antibiotic prescribing was reduced in the intervention area compared with control area (−4.3%, 95% confidence interval −7.1% to −1.5%). This result was robust to “sensitivity analysis” modifying the baseline period from two months (main analysis) to one month. A higher decrease was observed for penicillins resistant to β lactamase and a lower decrease for penicillins susceptible to β lactamase, consistent with the content of the newsletter on antibiotic resistance directed at health professionals. The decrease in expenditure on antibiotics was not statistically significant in a district level analysis with a two month baseline period (main analysis), but was statistically significant in sensitivity analyses using either a one month baseline period or a more powered doctor level analysis. Knowledge and attitudes of the target population about the correct use of antibiotics did not differ between the intervention and control areas.

Conclusions A local low cost information campaign targeted at citizens, combined with a newsletter on local antibiotic resistance targeted at doctors and pharmacists, was associated with significantly decreased total rates of antibiotic prescribing but did not affect the population’s knowledge and attitudes about antibiotic resistance.

Trial registration NCT01604096.


  • We thank Cinzia Del Giovane (University of Modena and Reggio Emilia, Italy) for reassuring us on statistical analysis; Luca Cisbani and Massimiliano Marchi (Emilia Romagna Regional Health and Social Care Agency) for providing data on hospital admissions; Roberto Da Cas (Italian National Health Institute, Rome Italy) for providing national prescribing data on antibiotics; and the six referees, whose suggestions helped us to produce better work.

  • Contributors: GF wrote the study protocol, coordinated the campaign design and implementation, did the statistical analysis, and drafted and revised the paper. He is guarantor. BP participated in the coordination of the campaign design and implementation and revised the final draft. AMM participated in the coordination of the campaign design and two television shows as part of the campaign, and revised the final draft. CG, AP, OC participated in the campaign design and presentation, and revised the final draft. MLM participated in the campaign design and revised the final draft. NM participated in the coordination of the campaign design and revised the final draft. Other members of the LOCAAL study group participated in the campaign design and implementation.

  • Funding: This study was funded through an Italian Medicines Agency grant (Bando AIFA 2008), raised through a compulsory contribution requested by law of pharmaceutical companies (5% of total promotional expenses).

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no individual support from any organisation for the submitted work aside from the Italian Medicines Agency grant (Bando AIFA 2008); no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work, which has not been scientifically influenced by the study sponsor in any way as well.

  • Ethical approval: The protocol was approved by the provincial ethics committees of Modena and Parma and is published in a peer reviewed journal and openly accessible at

  • Data sharing: The full dataset is available on request from the corresponding author at gformoso{at}

  • Other members of the LOCAAL Study Group: Dante Baronciani, Simona Di Mario, and Matteo Morandi (Emilia Romagna Regional Health and Social Care Agency); Silvana Quadrino, Mauro Doglio, Maria Assunta Longo, Alessandra Mattiola, Anna Mirenzi, and Manuela Olia (Change Institute, Turin, Italy); Massimiliano Laviola, Giuseppe Fattori, Valentina Solfrini, Paolo Barani, Massimo Bevini, Enrico Biagini, Roberto De Gesu, Margherita Di Pietro, Alfredo Ferrari, Maurizio Pontiroli, Mario Stancari, Lorenza Gamberini, Maria Angela Ghelfi, Carla Orsi, Maura Pagani, Mauro De Rosa, Maria Luisa De Luca, and Guido Pedrazzini (Local Health Authority, Via San Giovanni del Cantone Modena, Italy); Alberto Nico, Ettore Brianti, Bruno Bersellini, Maria Consolazione Coppola, Valter Corsi, Roberto Gallani, Carla Bertelli, Giovanna Negri, Rossella Emanuele, and Massimo Fabi (Local Health Authority, Parma, Italy); Luisa Canovi, Silvana Casale, and Livia Mosca (Federfarma Modena, and Farmacie Comunali Modena, Modena Italy); Giuseppe Franzan, Alessandro Merli, Fabrizio Piazza, and Maria Zoppi (Federfarma Parma and Farmacie Comunali Parma, Parma, Italy); Valter Bernabucci and Biagio Marsala (Creatività&Co communication agency, Parma, Italy); Jorge Frascara and Guillermina Noel (visual communication design consultants, Galleria Duomo Padova, Italy); Alessandra Salfi (SWG survey research, Milan, Italy).

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