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Meta-Analysis
. 2017 Sep 7;9(9):CD012252.
doi: 10.1002/14651858.CD012252.pub2.

Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews

Sarah Kg Tonkin-Crine  1 , Pui San Tan, Oliver van Hecke, Kay Wang, Nia W Roberts, Amanda McCullough, Malene Plejdrup Hansen, Christopher C Butler, Chris B Del Mar
Affiliations
Meta-Analysis

Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews

Sarah Kg Tonkin-Crine et al. Cochrane Database Syst Rev. .

Abstract

Background: Antibiotic resistance is a worldwide health threat. Interventions that reduce antibiotic prescribing by clinicians are expected to reduce antibiotic resistance. Disparate interventions to change antibiotic prescribing behaviour for acute respiratory infections (ARIs) have been trialled and meta-analysed, but not yet synthesised in an overview. This overview synthesises evidence from systematic reviews, rather than individual trials.

Objectives: To systematically review the existing evidence from systematic reviews on the effects of interventions aimed at influencing clinician antibiotic prescribing behaviour for ARIs in primary care.

Methods: We searched the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, CINAHL, PsycINFO, and Science Citation Index to June 2016. We also searched the reference lists of all included reviews. We ran a pre-publication search in May 2017 and placed additional studies in 'awaiting classification'.We included both Cochrane and non-Cochrane reviews of randomised controlled trials evaluating the effect of any clinician-focussed intervention on antibiotic prescribing behaviour in primary care. Two overview authors independently extracted data and assessed the methodological quality of included reviews using the ROBIS tool, with disagreements reached by consensus or by discussion with a third overview author. We used the GRADE system to assess the quality of evidence in included reviews. The results are presented as a narrative overview.

Main results: We included eight reviews in this overview: five Cochrane Reviews (33 included trials) and three non-Cochrane reviews (11 included trials). Three reviews (all Cochrane Reviews) scored low risk across all the ROBIS domains in Phase 2 and low risk of bias overall. The remaining five reviews scored high risk on Domain 4 of Phase 2 because the 'Risk of bias' assessment had not been specifically considered and discussed in the review Results and Conclusions. The trials included in the reviews varied in both size and risk of bias. Interventions were compared to usual care.Moderate-quality evidence indicated that C-reactive protein (CRP) point-of-care testing (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92, 3284 participants, 6 trials), shared decision making (odds ratio (OR) 0.44, 95% CI 0.26 to 0.75, 3274 participants, 3 trials; RR 0.64, 95% CI 0.49 to 0.84, 4623 participants, 2 trials; risk difference -18.44, 95% CI -27.24 to -9.65, 481,807 participants, 4 trials), and procalcitonin-guided management (adjusted OR 0.10, 95% CI 0.07 to 0.14, 1008 participants, 2 trials) probably reduce antibiotic prescribing in general practice. We found moderate-quality evidence that procalcitonin-guided management probably reduces antibiotic prescribing in emergency departments (adjusted OR 0.34, 95% CI 0.28 to 0.43, 2605 participants, 7 trials). The overall effect of these interventions was small (few achieving greater than 50% reduction in antibiotic prescribing, most about a quarter or less), but likely to be clinically important.Compared to usual care, shared decision making probably makes little or no difference to reconsultation for the same illness (RR 0.87, 95% CI 0.74 to 1.03, 1860 participants, 4 trials, moderate-quality evidence), and may make little or no difference to patient satisfaction (RR 0.86, 95% CI 0.57 to 1.30, 1110 participants, 2 trials, low-quality evidence). Similarly, CRP testing probably has little or no effect on patient satisfaction (RR 0.79, 95% CI 0.57 to 1.08, 689 participants, 2 trials, moderate-quality evidence) or reconsultation (RR 1.08, 95% CI 0.93 to 1.27, 5132 participants, 4 trials, moderate-quality evidence). Procalcitonin-guided management probably results in little or no difference in treatment failure in general practice compared to normal care (adjusted OR 0.95, 95% CI 0.73 to 1.24, 1008 participants, 2 trials, moderate-quality evidence), however it probably reduces treatment failure in the emergency department compared to usual care (adjusted OR 0.76, 95% CI 0.61 to 0.95, 2605 participants, 7 trials, moderate-quality evidence).The quality of evidence for interventions focused on clinician educational materials and decision support in reducing antibiotic prescribing in general practice was either low or very low (no pooled result reported) and trial results were highly heterogeneous, therefore we were unable draw conclusions about the effects of these interventions. The use of rapid viral diagnostics in emergency departments may have little or no effect on antibiotic prescribing (RR 0.86, 95% CI 0.61 to 1.22, 891 participants, 3 trials, low-quality evidence) and may result in little to no difference in reconsultation (RR 0.86, 95% CI 0.59 to 1.25, 200 participants, 1 trial, low-quality evidence).None of the trials in the included reviews reported on management costs for the treatment of an ARI or any associated complications.

Authors' conclusions: We found evidence that CRP testing, shared decision making, and procalcitonin-guided management reduce antibiotic prescribing for patients with ARIs in primary care. These interventions may therefore reduce overall antibiotic consumption and consequently antibiotic resistance. There do not appear to be negative effects of these interventions on the outcomes of patient satisfaction and reconsultation, although there was limited measurement of these outcomes in the trials. This should be rectified in future trials.We could gather no information about the costs of management, and this along with the paucity of measurements meant that it was difficult to weigh the benefits and costs of implementing these interventions in practice.Most of this research was undertaken in high-income countries, and it may not generalise to other settings. The quality of evidence for the interventions of educational materials and tools for patients and clinicians was either low or very low, which prevented us from drawing any conclusions. High-quality trials are needed to further investigate these interventions.

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Conflict of interest statement

Sarah Tonkin‐Crine is a health psychologist funded by the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England.

Pui San Tan is an infectious diseases and acute care postdoctoral researcher funded by the NIHR under its Programme Grants for Applied Research Programme (RP‐PG‐ 0514‐20015).

Oliver van Hecke is a general practitioner and clinical research fellow at the University of Oxford, funded by the NIHR under its Programme Grants for Applied Research Programme (RP‐PG‐1210‐12012).

Kay Wang is a NIHR postdoctoral fellow at the University of Oxford.

Nia Roberts: none known.

Amanda McCullough is a postdoctoral fellow at the Centre for Research Excellence in Minimising Antibiotic Resistance from Acute Respiratory Infections (CREMARA) funded by the National Health and Medical Research Council (NHMRC), Australia (1044904).

Malene Plejdrup Hansen was a postdoctoral fellow at the Centre for Research Excellence in Minimising Antibiotic Resistance from Acute Respiratory Infections (CREMARA) funded by the National Health and Medical Research Council (NHMRC), Australia (1044904), and is a senior research fellow at the Research Unit for General Practice in Aalborg funded by the Research Foundation of General Practice in Denmark.

Christopher C Butler has held research grants to develop, evaluate and implement antibiotic stewardship interventions. He has received honoraria from Alere and Roche for contributions about point of care diagnostics. The honorarium from Roche did not relate to this review in any way. He is the chief investigator of the publicly funded PACE study that is assessing C‐reactive protein point of care testing (CRP POCT) to guide antibiotic treatment for acute exacerbations of chronic obstructive airways disease. Alere has provided the CRP POCT devices and associated support as an unconditional educational grant free to the study. He also receives support from the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford, and holds several publicly funded grants to conduct research in the field of infections. No commercial funding was received from any source to conduct this review.

Chris B Del Mar is co‐ordinating editor of the Cochrane Acute Respiratory Infections Group and chief investigator at the Centre for Research Excellence in Minimising Antibiotic Resistance from Acute Respiratory Infections (CREMARA) funded by the National Health and Medical Research Council (NHMRC), Australia (1044904). He received royalties from BMJ Books and Elsevier for activities unrelated to this submitted work.

Figures

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Study flow diagram.
See this image and copyright information in PMC

Comment in

References

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