Implementing AHRQ Effective Health Care Reviews

Helping Clinicians Make Better Treatment Choices

Interventions to Improve Antibiotic Prescribing for Uncomplicated Acute RTIs

 

Am Fam Physician. 2016 Dec 1;94(11):918-920.

Author disclosure: No relevant financial affiliations.

Key Clinical Issue

What are the effectiveness and adverse consequences of strategies for reducing antibiotic use in adults and children with uncomplicated acute respiratory tract infections (RTIs)?

Evidence-Based Answer

Procalcitonin point-of-care testing reduces antibiotic prescribing in adults (Strength of recommendation [SOR]: A, based on consistent, good-quality patient-oriented evidence), but increases antibiotic prescribing and adverse consequences in children. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Rapid streptococcal antigen point-of-care testing, viral polymerase chain reaction testing (adults only), and C-reactive protein testing reduced antibiotic prescribing, but studies of adverse consequences were lacking. Delayed prescribing practices reduced antibiotic prescribing, but reduced patient satisfaction and increased symptom length. (SOR: A, based on consistent, good-quality patient-oriented evidence.) Electronic decision supports reduced antibiotic prescribing without affecting the risk of complications.

Practice Pointers

Antibiotic-resistant bacterial infections lead to approximately 23,000 deaths in the United States each year.1 Inappropriate antibiotic prescribing is the leading cause of resistance and accounts for one-third of all antibiotic prescriptions each year.2  Clinical, system-level, or educational interventions that reduce inappropriate prescribing (eTable A and eTable B) have the potential to dramatically decrease deaths and slow the progression of resistant organisms.

View/Print Table

eTable A.

Categories of Interventions to Reduce Antibiotic Prescribing

CategoryExplanations and examples

Clinical

Point-of-care tests to rapidly determine the likelihood that a patient has a specific infection (e.g., rapid streptococcal antigen test of a throat swab sample, multiviral polymerase chain reaction, or an influenza-specific test of throat or nasopharyngeal secretions) or has a bacterial infection instead of a viral one (e.g., blood procalcitonin, blood C-reactive protein); tympanometry to aid in diagnosing acute otitis media; delayed antibiotic prescribing (e.g., giving prescriptions to patients with instructions to delay filling, leaving prescriptions for patient collection, postdating prescriptions, requesting recontact with physician); clinical scoring tools based on combinations of signs and symptoms

System-level

Electronic decision support (computer-aided, evidence-based prescribing recommendations); paper-based physician reminders about prescribing; physician audit plus feedback; financial or regulatory incentives for physicians or patients; antimicrobial stewardship programs

Educational

Clinic-based patient or parent education about when antibiotics may be appropriate (e.g., videos, pamphlets, verbal education, waiting room posters); public education campaigns (e.g., billboards, bus advertisements, radio and television advertisements); clinician education about current treatment guidelines; communication skills training programs for physicians

Multifaceted

Combination of interventions from one or more categories


Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Improving antibiotic prescribing for uncomplicated acute respiratory tract infections. Clinician research summary. Rockville, Md.: Agency for Healthcare Research and Quality; January 2016. https://www.effectivehealthcare.ahrq.gov/ehc/products/561/2112/antibiotics-respiratory-infection-report-160128.pdf. Accessed June 27, 2016.

eTable A.

Categories of Interventions to Reduce Antibiotic Prescribing

CategoryExplanations and examples

Clinical

Point-of-care tests to rapidly determine the likelihood that a patient has a specific infection (e.g., rapid streptococcal antigen test of a throat swab sample, multiviral polymerase chain reaction, or an influenza-specific test of throat or nasopharyngeal secretions) or has a bacterial infection instead of a viral one (e.g., blood procalcitonin, blood C-reactive protein); tympanometry to aid in diagnosing acute otitis media; delayed antibiotic prescribing (e.g., giving prescriptions to patients with instructions to delay filling, leaving prescriptions for patient collection, postdating prescriptions, requesting recontact with physician); clinical scoring tools based on combinations of signs and symptoms

System-level

Electronic decision support (computer-aided, evidence-based prescribing recommendations); paper-based physician reminders about prescribing; physician audit plus feedback; financial or regulatory incentives for physicians or patients; antimicrobial stewardship programs

Educational

Clinic-based patient or parent education about when antibiotics may be appropriate (e.g., videos, pamphlets, verbal education, waiting room posters); public education campaigns (e.g., billboards, bus advertisements, radio and television advertisements); clinician education about current treatment guidelines; communication skills training programs for

Address correspondence to Aaron Saguil, MD, MPH, at asaguil@usuhs.mil. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

REFERENCES

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1. Agency for Healthcare Research and Quality, Effective Healthcare Program. Improving antibiotic prescribing for uncomplicated acute respiratory tract infections. Clinician research summary. Rockville, Md.: Agency for Healthcare Research and Quality; January 2016. https://www.effectivehealthcare.ahrq.gov/ehc/products/561/2112/antibiotics-respiratory-infection-report-160128.pdf. Accessed June 27, 2016....

2. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA. 2016;315(17):1864–1873.

3. Snellman L, Adams W, Anderson G, et al. Institute for Clinical Systems Improvement. Diagnosis and treatment of respiratory illness in children and adults. Updated January 2013. https://www.icsi.org/_asset/1wp8x2/RespIllness.pdf. Accessed May 22, 2016.

4. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media [published correction appears in Pediatrics. 2014;133(2):346]. Pediatrics. 2013;131(3):e964–e999.

5. Tell D, Engström S, Mölstad S. Adherence to guidelines on antibiotic treatment for respiratory tract infections in various categories of physicians: a retrospective cross-sectional study of data from electronic patient records. BMJ Open. 2015;5(7):e008096.

6. Marc C, Vrignaud B, Levieux K, Robine A, Gras-Le Guen C, Launay E. Inappropriate prescription of antibiotics in pediatric practice: analysis of the prescriptions in primary care [published ahead of print April 18, 2016]. J Child Health Care. http://chc.sagepub.com/content/early/2016/04/13/1367493516643421.long (subscription required). Accessed August 12, 2016.

7. Gidengil CA, Mehrotra A, Beach S, Setodji C, Hunter G, Linder JA. What drives variation in antibiotic prescribing for acute respiratory infections? J Gen Intern Med. 2016;31(8):918–924.

8. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2014;58(10):1496]. Clin Infect Dis. 2012;55(10):1279–1282.

9. The Management of Chronic Obstructive Pulmonary Disease Working Group. VA/DoD clinical practice guideline for the management of chronic obstructive pulmonary disease. Washington, DC: Dept. of Veterans Affairs, Dept. of Defense; December 2014. http://www.healthquality.va.gov/guidelines/CD/copd/VADoDCOPDCPG.pdf. Accessed June 13, 2016.

10. National Institute for Health and Care Excellence. Procalcitonin testing for diagnosing and monitoring sepsis (ADVIA Centaur BRAHMS PCT assay, BRAHMS PCT Sensitive Kryptor assay, Elecsys BRAHMS PCT assay, LIAISON BRAHMS PCT assay and VIDAS BRAHMS PCT assay). London, UK: National Institute for Health and Care Excellence; October 2015. https://www.nice.org.uk/guidance/dg18. Accessed June 13, 2016.

11. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580–637.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based upon the review. AHRQ's summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions. For the full review, clinician summary, and consumer summary, go to http://www.effectivehealthcare.ahrq.gov/antibiotics-RTI.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.


 

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