Carling 2003.

Methods	STUDY DESIGN: ITS Risk of Bias: MEDIUM
Participants	PROVIDERS: all physicians in the hospital PARTICIPANTS: all patients in the hospital CLINICAL PROBLEM: NOT CLEAR SETTING: 1 community teaching hospital in the USA
Interventions	FORMAT: no valid prescribing data. Educational outreach ‐ review and recommend change; educational meetings with dissemination of educational materials DELIVERER: AMT COMPARISON: usual care DESIRED CHANGE: decrease excessive
Outcomes	MICROBIAL: prevalence of Clostridium difficile, ceftazidime‐resistant Enterobacteriaceae, and MRSA FINANCIAL: cost of intervention
Notes	FINANCIAL SUPPORT: Funding: institutional support. Competing Interests: none declared ADDITIONAL DATA: no additional data requested
Risk of bias
Bias	Authors' judgement	Support for judgement
Intervention independent (ITS) ?	Low risk	3 years' pre‐intervention data
Analysed appropriately (ITS) ?	Low risk	Done in original paper: regression analysis with adjustment for autocorrelation. Analysis repeated by review team because of incomplete reporting of results.
Shape of effect pre‐specified (ITS) ?	Low risk	Done, intended effect was decrease in primary outcome, and point of analysis was point of intervention.
Unlikely to affect data collection (ITS) ?	Low risk	Done, data were from routine systems and unlikely to change over study period.
Knowledge of the allocation adequately prevented(ITS)?	Low risk	Done, data were from routine systems and unlikely to change over study period.
Incomplete outcome data addressed (ITS) ?	Low risk	Done, data were from routine systems and unlikely to change over study period.
Free of selected reporting (ITS) ?	Unclear risk	Not clear, no information about changes in sampling or testing protocol over study period.
Free of other bias (ITS) ?	Low risk	VRE isolation unlikely to have influenced C difficile or resistant gram‐negative bacteria. Microbial Risk of Bias Criteria: Planned intervention: DONE Implementation of antimicrobial management team in response to increase in use of target drugs. Case definition: DONE for C difficile infection (diarrhoea and toxin positive) or infection with clinical isolates of gram‐negative bacteria resistant to ceftazidime, or MRSA (CDC definition of nosocomial infection). Other infection control measures: DONE For C difficile contact precautions and procedures for cleansing equipment and patient care areas remained unchanged. Other infection control processes are not described in detail but may have changed during the study period (e.g. VRE isolation introduced after intervention). Data about VRE infections NOT RELIABLE: There were no cases in the pre‐intervention phase and none in the first 3 years postintervention, but there was an outbreak in the 4th and 5th postintervention years caused by admission of patients from other hospitals who were colonised with VRE.