Interventions to Reduce Antibiotic Prescribing for Uncomplicated Acute Respiratory Tract Infections [Entered Retrospectively]

Project Summary Title and Description

Title
Interventions to Reduce Antibiotic Prescribing for Uncomplicated Acute Respiratory Tract Infections [Entered Retrospectively]
Description
Objectives. To assess the comparative effectiveness of interventions for reducing antibiotic use for acute respiratory tract infections (RTIs) in adults and children. Data Sources. Electronic databases (MEDLINE® from 1990 and the Cochrane Library databases from 2005 to February 2015), reference lists of included systematic reviews, and scientific information packets from of point-of-care test manufacturers and experts. Review Methods. Using predefined criteria, we selected studies of any intervention designed to reduce antibiotic prescribing for acute RTIs. Interventions were organized into educational, communication, clinical, system level, and multifaceted categories. The key outcome was change in prescribing; secondary outcomes were undesirable consequences such as medical complications and satisfaction. The quality of included studies was rated and the strength of the evidence was assessed. Clinical and methodological heterogeneity limited quantitative analysis. Our synthesis focused on interventions that had evidence of net benefit: at least moderate strength of evidence for decreasing overall prescribing of antibiotics for acute RTI and at least low strength evidence for other outcomes. Results. Based on 132 studies, including 88 randomized controlled trials, several interventions had net benefit. Compared with usual care, reductions in overall prescribing were 21 percent for clinic-based educational programs for parents, 7 percent for public education campaigns combined with clinician education, 9 to 26 percent for communication training, 5 to 9 percent for electronic decision support, 2 to 34 percent for C-reactive protein (CRP), 12 to 72 percent for procalcitonin in adults, and >25 percent for clinician communication training plus CRP testing. Delayed prescribing reduced use by 34 to 76 percent compared with immediate prescribing. Additionally, public education campaigns combined with clinician education and electronic decision support possibly improved appropriate prescribing. Interventions varied in their effects on other outcomes. Few studies assessed impact on the most serious undesirable outcomes, but in those that did, there were no increases in medical complications for public education campaigns combined with clinician education or electronic decision support and, for hospitalizations, no increases for CRP or procalcitonin and only a slight increase for communication+CRP. Negative impacts on less serious outcomes were few and small: more return visits with CRP testing, slightly longer symptom duration with communication training plus CRP testing, and decreased patient satisfaction and slightly longer symptom duration with delayed prescribing. Direct comparisons of interventions were few; only clinician communication training plus CRP testing showed net benefit over CRP testing alone. Interventions with no or negative impact on antibiotic prescribing were procalcitonin in children, clinic-based education for parents of children ≤24 months with acute otitis media, and point-of-care testing for influenza in children. Conclusions. Interventions from all categories had evidence of net benefit and no serious adverse consequences. Magnitude of benefit varied widely and current evidence is inadequate to determine key modifying factors. Future studies need to better evaluate potential effect modifiers, and directly compare the effective interventions individually and combined, on net benefit, sustainability, and resource use.
Attribution
N/A
Authors of Report
N/A
Methodology description
Using predefined criteria, we selected studies of any intervention designed to reduce antibiotic prescribing for acute RTIs. Interventions were organized into educational, communication, clinical, system level, and multifaceted categories. The key outcome was change in prescribing; secondary outcomes were undesirable consequences such as medical complications and satisfaction. The quality of included studies was rated and the strength of the evidence was assessed. Clinical and methodological heterogeneity limited quantitative analysis. Our synthesis focused on interventions that had evidence of net benefit: at least moderate strength of evidence for decreasing overall prescribing of antibiotics for acute RTI and at least low strength evidence for other outcomes.
PROSPERO
CRD42014010094
DOI
10.7301/Z06H4FBG
Notes
The published report is available at the following link: www.effectivehealthcare.ahrq.gov. Data were entered retrospectively and data abstraction and quality assessment evidence tables can be found in Appendices D through I, which have been uploaded and attached to this project.
Funding Source
This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA290201200014I).

Key Questions

1. Key Question 1. For patients with an acute respiratory tract infection and no clear indication for antibiotic treatment, what is the comparative effectiveness of particular strategies in improving the appropriate prescription or use of antibiotics compared with other strategies or standard care? a) Does the comparative effectiveness of strategies differ according to how appropriateness is defined? b) Does the comparative effectiveness of strategies differ according to the intended target of the strategy (i.e., clinicians, patients, and both)? c) Does the comparative effectiveness of strategies differ according to patient characteristics, such as type of respiratory tract infection, signs and symptoms (nature and duration), when counting began for duration of symptoms, previous medical history (e.g., frailty, comorbidity), prior respiratory tract infections, prior use of antibiotics, age, ethnicity, socioeconomic status, and educational level attained? d) Does the comparative effectiveness of strategies differ according to clinician characteristics, such as specialty, number of years in practice, type of clinic organization, geographic region, and population served? e) Does the comparative effectiveness differ according to the diagnostic method or definition used, the clinician’s perception of the patient’s illness severity, or the clinician’s diagnostic certainty? f) Does the comparative effectiveness differ according to various background contextual factors, such as the time of year, known patterns of disease activity (e.g., an influenza epidemic, a pertussis outbreak), system level characteristics, or whether the intervention was locally tailored?
2. Key Question 2. For patients with an acute respiratory tract infection and no clear indication for antibiotic treatment, what is the comparative effect of particular strategies on antibiotic resistance compared with other strategies or standard care? a) Does the comparative effect of strategies differ according to the intended target of the strategy (i.e., clinicians, patients, and both)? b) Does the comparative effect of strategies differ according to patient characteristics, such as type of respiratory tract infection, signs and symptoms (nature and duration), when counting began for duration of symptoms, previous medical history (e.g., frailty, comorbidity), prior respiratory tract infections, prior use of antibiotics, age, ethnicity, socioeconomic status, and educational level attained? c) Does the comparative effect of strategies differ according to clinician characteristics, such as specialty, number of years in practice, type of clinic organization, geographic region, and population served? d) Does the comparative effectiveness differ according to the diagnostic method or definition used, the clinician’s perception of the patient’s illness severity, or the clinician’s diagnostic certainty? e) Does the comparative effect differ according to various background contextual factors, such as the time of year, known patterns of disease activity (e.g., an influenza epidemic, a pertussis outbreak), whether the intervention was locally tailored, system-level characteristics, or the source of the resistance data (i.e., population vs. study sample)?
3. Key Question 3. For patients with an acute respiratory tract infection and no clear indication for antibiotic treatment, what is the comparative effect of particular strategies on medical complications (including mortality, hospitalization and adverse effects of receiving or not receiving antibiotics) compared with other strategies or standard care? a) Does the comparative effect of strategies differ according to the intended target of the strategy (i.e., clinicians, patients, and both)? b) Does the comparative effect of strategies differ according to patient characteristics, such as type of respiratory tract infection, signs and symptoms (nature and duration), when counting began for duration of symptoms, previous medical history (e.g., frailty, comorbidity), prior respiratory tract infections, prior use of antibiotics, age, ethnicity, socioeconomic status, and educational level attained? c) Does the comparative effect of strategies differ according to clinician characteristics, such as specialty, number of years in practice, type of clinic organization, geographic region, and population served? d) Does the comparative effectiveness differ according to the diagnostic method or definition used, the clinician’s perception of the patient’s illness severity, or the clinician’s diagnostic certainty? e) Does the comparative effect differ according to various background contextual factors, such as the time of year, known patterns of disease activity (e.g., an influenza epidemic, a pertussis outbreak), whether the intervention was locally tailored or system-level characteristics?
4. Key Question 4. For patients with an acute respiratory tract infection and no clear indication for antibiotic treatment, what is the comparative effect of particular strategies on other clinical outcomes (e.g., health care utilization, patient satisfaction) compared with other strategies or standard care? a) Does the comparative effect of strategies differ according to the intended target of the strategy (i.e., clinicians, patients, and both)? b) Does the comparative effect of strategies differ according to patient characteristics, such as type of respiratory tract infection, signs and symptoms (nature and duration), when counting began for duration of symptoms, previous medical history (e.g., frailty, comorbidity), prior respiratory tract infections, prior use of antibiotics, age, ethnicity, socioeconomic status, and educational level attained? c) Does the comparative effect of strategies differ according to clinician characteristics, such as specialty, number of years in practice, type of clinic organization, geographic region, and population served? d) Does the comparative effectiveness differ according to the diagnostic method or definition used, the clinician’s perception of the patient’s illness severity, or the clinician’s diagnostic certainty? e) Does the comparative effect differ according to various background contextual factors, such as the time of year, known patterns of disease activity (e.g., an influenza epidemic, a pertussis outbreak), whether the intervention was locally tailored or system-level characteristics?
5. Key Question 5. For patients with an acute respiratory tract infection and no clear indication for antibiotic treatment, what is the comparative effect of particular strategies on achieving intended intermediate outcomes, such as improved knowledge regarding use of antibiotics for acute respiratory tract infections (clinicians and/or patients), improved shared decisionmaking regarding the use of antibiotics, and improved clinician skills for appropriate antibiotic use (e.g., communication appropriate for patients’ literacy level and/or cultural background)?
6. Key Question 6. What are the comparative nonclinical adverse effects of strategies for improving the appropriate use of antibiotics for acute respiratory tract infections (e.g., increased time burden on clinicians, patients, clinic staff)?

Associated Extraction Forms

Associated Studies (each link opens a new tab)

TitleAuthorsYear
Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study.2007
Evaluation of a patient education manual.1980
Communication training and antibiotic use in acute respiratory tract infections. A cluster randomised controlled trial in general practice.2006
Access to a polymerase chain reaction assay method targeting 13 respiratory viruses can reduce antibiotics: a randomised, controlled trial.2011
The effect of alternative graphical displays used to present the benefits of antibiotics for sore throat on decisions about whether to seek treatment: a randomized trial.
Comparison of two approaches to observation therapy for acute otitis media in the emergency department.2008
A randomized controlled trial of point-of-care evidence to improve the antibiotic prescribing practices for otitis media in children.2001
A cluster randomized clinical trial to improve prescribing patterns in ambulatory pediatrics.
A randomised controlled trial of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care.2001
Immediate vs. delayed treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin V.1991
Improving adherence to otitis media guidelines with clinical decision support and physician feedback.2013
Improving antibiotic prescribing in acute respiratory tract infections: cluster randomised trial from Norwegian general practice (prescription peer academic detailing (Rx-PAD) study).
Parental knowledge about antibiotic use: results of a cluster-randomized, multicommunity intervention.2007
Effect of point-of-care influenza testing on management of febrile children.2006
Training family physicians in shared decision making for the use of antibiotics for acute respiratory infections: a pilot clustered randomized controlled trial.2011
Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial.2012
Electronic health record feedback to improve antibiotic prescribing for acute respiratory infections.2010
Open randomised trial of prescribing strategies in managing sore throat.1997
Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management).
Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study.2014
Impact on antibiotic prescription of rapid antigen detection testing in acute pharyngitis in adults: a randomised clinical trial.2011
An evaluation of statewide strategies to reduce antibiotic overuse.2000
Nonsevere acute otitis media: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment.2005
Effect on antibiotic prescribing of repeated clinical prompts to use a sore throat score: lessons from a failed community intervention study.
Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial.
Adverse and beneficial effects of immediate treatment of Group A beta-hemolytic streptococcal pharyngitis with penicillin.1987
Accuracy and impact of a point-of-care rapid influenza test in young children with respiratory illnesses.2006
Debiasing effects of education about appropriate antibiotic use on consumers' preferences for physicians.-- Not Found --
Acute otitis media--a brief explanation to parents and antibiotic use.2003
Reduction in antibiotic use following a cluster randomized controlled multifaceted intervention: the Israeli judicious antibiotic prescription study.2011
Minor illness education for parents of young children.2003
Reducing physician visits for colds through consumer education.1983
Animated video vs pamphlet: comparing the success of educating parents about proper antibiotic use.2010
Effectiveness of an educational intervention in modifying parental attitudes about antibiotic usage in children.
What is the role of quality circles in strategies to optimise antibiotic prescribing? A pragmatic cluster-randomised controlled trial in primary care.2007
Changing GPs' antibiotic prescribing: a randomised controlled trial.2003
Effect of intervention promoting a reduction in antibiotic prescribing by improvement of diagnostic procedures: a prospective, before and after study in general practice.2006
Evaluation of a drug therapy protocol in an HMO.1979
Introducing a multifaceted intervention to improve the management of otitis media: how do pediatricians, internists, and family physicians respond?-- Not Found --
Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults.1999
Impact of a health literacy intervention on pediatric emergency department use.2009
Community intervention to promote rational treatment of acute respiratory infection in rural Nepal.2009
Standardized instructions: do they improve communication of discharge information from the emergency department?1992
Effect of two interventions on reducing antibiotic prescription in pharyngitis in primary care.2011
C-reactive protein testing in patients with acute rhinosinusitis leads to a reduction in antibiotic use.2012
Evaluation of the Do Bugs Need Drugs? program in British Columbia: Can we curb antibiotic prescribing?2011
Changes in antibiotic prescribing for children after a community-wide campaign.2002
Impact of a waiting room videotape message on parent attitudes toward pediatric antibiotic use.2001
Biomarkers as point-of-care tests to guide prescription of antibiotics in patients with acute respiratory infections in primary care.2014
Rapid viral diagnosis for acute febrile respiratory illness in children in the Emergency Department.
Procalcitonin algorithms for antibiotic therapy decisions: a systematic review of randomized controlled trials and recommendations for clinical algorithms.2011
Improving parent knowledge about antibiotics: a video intervention.2001
Effectiveness of Centers for Disease Control and Prevention recommendations for outcomes of acute otitis media.2006
Impact of the rapid diagnosis of influenza on physician decision-making and patient management in the pediatric emergency department: results of a randomized, prospective, controlled trial.2003
Procalcitonin-guided antibiotic use vs a standard approach for acute respiratory tract infections in primary care.2008
Procalcitonin guidance and reduction of antibiotic use in acute respiratory tract infection.2010
Point-of-care C-reactive protein testing and antibiotic prescribing for respiratory tract infections: a randomized controlled trial.-- Not Found --
Antibiotic consumption successfully reduced by a community intervention program.2007
Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial.2004
Optimizing antibiotic prescribing for acute cough in general practice: a cluster-randomized controlled trial.2004
Randomised controlled trial of CRP rapid test as a guide to treatment of respiratory infections in general practice.2000
A randomized controlled trial to change antibiotic prescribing patterns in a community.2004
Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts.2008
Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial.
Lack of impact of early antibiotic therapy for streptococcal pharyngitis on recurrence rates.1990
Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial.2013
C-reactive protein testing does not decrease antibiotic use for acute cough illness when compared to a clinical algorithm.2011
Improvements in antimicrobial prescribing for treatment of upper respiratory tract infections through provider education.2005
Documentation-based clinical decision support to improve antibiotic prescribing for acute respiratory infections in primary care: a cluster randomised controlled trial.2009
Cluster-randomized trial to improve antibiotic use for adults with acute respiratory infections treated in emergency departments.
Theory-based interventions to reduce prescription of antibiotics--a randomized controlled trial in Sweden.2013
Effect of antibiotic prescribing strategies and an information leaflet on longer-term reconsultation for acute lower respiratory tract infection.2009
The effect of rapid diagnostic testing for influenza on the reduction of antibiotic use in paediatric emergency department.2009
Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial.2009
Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial.2006
Effectiveness of a parental educational intervention in reducing antibiotic use in children: a randomized controlled trial.2005
Randomised controlled trial of effect of Baby Check on use of health services in first 6 months of life.1999
Development and randomized controlled trial of a booklet of advice for parents.1991
Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised controlled trial.2004
Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme.2011
A National Study of the Impact of Rapid Influenza Testing on Clinical Care in the Emergency Department.2014
Antibiotic treatment of acute respiratory tract infections in the elderly: effect of a multidimensional educational intervention.2004
Optimizing antibiotic prescribing for acute respiratory tract infections in an urban urgent care clinic.2003
Use of an electronic health record clinical decision support tool to improve antibiotic prescribing for acute respiratory infections: the ABX-TRIP study.2013
Effectiveness of two types of intervention on antibiotic prescribing in respiratory tract infections in Primary Care in Spain. Happy Audit Study.2014
Impact of a clinical decision support system on antibiotic prescribing for acute respiratory infections in primary care: quasi-experimental trial.-- Not Found --
Changing parents' opinions regarding antibiotic use in primary care.2011
Effect of educational intervention on antibiotic prescription practices for upper respiratory infections in children: a multicentre study.2005
Intervention with educational outreach at large scale to reduce antibiotics for respiratory tract infections: a controlled before and after study.2009
Influence of self-registration on audit participants and their non-participating colleagues. A retrospective study of medical records concerning prescription patterns.2005
Delayed antibiotics for respiratory infections.2013
Do delayed prescriptions reduce the use of antibiotics for the common cold? A single-blind controlled trial.
Procalcitonin guidance to reduce antibiotic treatment of lower respiratory tract infection in children and adolescents (ProPAED): a randomized controlled trial.
Improving referrals for glue ear from primary care: are multiple interventions better than one alone?2001
Impact of a computerized template on antibiotic prescribing for acute respiratory infections in children and adolescents.2010
Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial.2009
Impact of a child care educational intervention on parent knowledge about appropriate antibiotic use.2007
A randomized, controlled trial of the impact of early and rapid diagnosis of viral infections in children brought to an emergency department with febrile respiratory tract illnesses.2009
Reducing antibiotic use in children: a randomized trial in 12 practices.2001
A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis.2013
Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media.2001
Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial.2013
Reducing antibiotic use for acute bronchitis in primary care: blinded, randomised controlled trial of patient information leaflet.2002
Improving pediatricians' compliance-enhancing practices. A randomized trial.1988
Evaluation of a rapid antigen detection test in the diagnosis of streptococcal pharyngitis in children and its impact on antibiotic prescription.2008
Computerized algorithms and pediatricians' management of common problems in a community clinic.1992
Efficacy of an evidence-based clinical decision support in primary care practices: a randomized clinical trial.2013
Clinical decision support and appropriateness of antimicrobial prescribing: a randomized trial.2005
Mailed prescriber feedback in addition to a clinical guideline has no impact: a randomised, controlled trial.2003
A randomized clinical trial to assess the effects of tympanometry on the diagnosis and treatment of acute otitis media.
Antibiotic selection patterns in acutely febrile new outpatients with or without immediate testing for C reactive protein and leucocyte count.2005
Diagnosing streptococcal sore throat in adults: randomized controlled trial of in-office aids.2007
Postdated versus usual delayed antibiotic prescriptions in primary care: Reduction in antibiotic use for acute respiratory infections?2010
Educational posters to reduce antibiotic use.-- Not Found --
C-reactive protein measurement in general practice may lead to lower antibiotic prescribing for sinusitis.2004
Effect of standard treatment guidelines with or without prescription audit on prescribing for acute respiratory tract infection (ARI) and diarrhoea in some thana health complexes (THCs) of Bangladesh.2007
"Get smart Colorado": impact of a mass media campaign to improve community antibiotic use.2008
Can a nationwide media campaign affect antibiotic use?2009
The English antibiotic awareness campaigns: did they change the public's knowledge of and attitudes to antibiotic use?2010
A sustainable strategy to prevent misuse of antibiotics for acute respiratory infections.
A multifaceted education intervention for improving family physicians' case management.2009
A multifaceted intervention to improve antimicrobial prescribing for upper respiratory tract infections in a small rural community.
A safety-net antibiotic prescription for otitis media: the effects of a PBRN study on patients and practitioners.2006
Educational intervention for parents and healthcare providers leads to reduced antibiotic use in acute otitis media.2002
The effect of a community intervention trial on parental knowledge and awareness of antibiotic resistance and appropriate antibiotic use in children.2001
Effectiveness of interventions in reducing antibiotic use for upper respiratory infections in ambulatory care practices.2013
Impact of a multipronged education strategy on antibiotic prescribing in Quebec, Canada.2011
Evaluation of a national programme to reduce inappropriate use of antibiotics for upper respiratory tract infections: effects on consumer awareness, beliefs, attitudes and behaviour in Australia.2007
Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial.2014
Association between point-of-care CRP testing and antibiotic prescribing in respiratory tract infections: a systematic review and meta-analysis of primary care studies.2013
Reducing Parental Demand for Antibiotics by Promoting Communication Skills2005
Medico-economic evaluation of an educational intervention to optimize children uncomplicated nasopharyngitis treatment in ambulatory care.2000
Realities of Practice: Development and Implementation of Clinical Practice Guidelines for Acute Respiratory Infections in Young Children (PhD Thesis)2002

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