A new Cochrane Review has identified three clinician-focused strategies that may reduce antibiotic prescribing for acute respiratory infections (ARIs) in primary care settings.
The review found moderate-quality evidence that C-reactive protein (CRP) point-of-care testing, shared decision making between patients and clinicians, and procalcitonin-guided management probably reduce antibiotic prescribing for patients with ARIs, and therefore may reduce overall antibiotic consumption.
The authors of the review say the overall effect of these interventions was small, with few achieving greater than 50% reduction in antibiotic prescribing, but the impact is likely to be clinically important. They note, however, that since none of the reviewed studies compared these interventions against one another, they cannot say which are most effective.
The authors also found that the quality of evidence for other antibiotic prescribing interventions in ARI management was either low or very low, and suggest more research is needed to be able to determine the clinical value of these strategies.
Cochrane Reviews are systematic reviews of randomized, controlled trials that look at the effects of medical interventions for prevention, treatment, and rehabilitation. They are considered the gold standard in evidence-based medicine.
Influencing prescriber behavior
ARIs—which include conditions such as bronchitis, sinusitis, pharyngitis, and acute otitis media—are considered a significant driver of antibiotic use in primary care settings and consequently a major factor in antibiotic resistance. In the United States, more than 40 million antibiotic prescriptions annually target respiratory conditions. But since many of these illnesses are viral in nature and don't require antibiotics, ARIs are a major target for antibiotic stewardship interventions.
Many of these interventions aim to influence the prescribing behavior of primary care physicians. They include point-of-care tests that can help reduce the uncertainty of clinical diagnosis, educational meetings and materials, audit and feedback on prescribing habits, financial incentives, and communication strategies that help encourage discussions with patients about treatment options. Other interventions focus on greater patient education, since patient pressure for antibiotics, and how clinicians perceive that pressure, is considered a factor in antibiotic prescribing.
To get a sense of how effective these interventions have been at reducing antibiotic prescribing for ARIs, the authors reviewed the existing evidence from eight previously published systematic reviews (five Cochrane Reviews and three non-Cochrane Reviews), which contained a total of 44 randomized clinical trials. In these trials, interventions were compared to usual care. The aim of this review was to synthesize the evidence from the existing reviews and determine which interventions have lowered antibiotic prescriptions for ARIs.
Most of the reviews focused on the effects of point-of-care diagnostic tests, including CRP and procalcitonin tests. These are blood tests that look for C-reactive protein and the hormone procalcitonin, which can be biomarkers of inflammation and infection. While these tests are not foolproof, they can help reduce diagnostic uncertainty.
In their analysis of the included reviews and trials, the authors found moderate-quality evidence that both CRP testing and procalcitonin-guided management probably reduces antibiotic prescribing in primary care, with CRP testing showing little or no effect on symptom duration, patient satisfaction, or reconsultation for the same illness. They also found moderate-quality evidence that procalcitonin-guided management probably reduces antibiotic prescribing in emergency departments.
Among the communication strategies, there was moderate-quality evidence that shared decision making—a model in which clinicians provide patients with information about all options and help them identify their treatment preference—probably reduces antibiotic prescribing without increasing the likelihood of reconsultation, but makes little or no difference in patient satisfaction.
"We found evidence that CRP testing, shared decision making, and procalcitonin-guided management reduce antibiotic prescribing for patients with ARIs in primary care," the authors conclude. "These interventions may therefore reduce overall antibiotic consumption and consequently antibiotic resistance."
The quality of evidence found in the systematic reviews for rapid viral diagnostic tests, which can differentiate between viral and bacterial infections, was low, which meant the authors were unable to draw firm conclusions about their effectiveness in reducing antibiotic prescribing when compared with usual care. That was also the case for other stewardship approaches, including printed educational materials for clinicians, audit and feedback interventions, patient information leaflets, and interventions that combined several different strategies.
The authors note that none of the trials included in the reviews reported on management costs, making it difficult to draw conclusions on the cost-effectiveness of the respective interventions. In addition, since all the research was undertaken in high-income countries, the findings may not be applicable to other settings.
Sep 7 Cochrane Review