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

Tonkin‐Crine, Sarah; Tan, Pui San; Hecke, Oliver van; Wang, Kay; Roberts, Nia; McCullough, Amanda; Hansen, Malene Plejdrup; Butler, Christopher Collett; Mar, Chris Del

doi:10.1002/14651858.cd012252.pub2

Cited by 149 publications

(161 citation statements)

References 74 publications

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“…Systematic review evidence suggests that shared decision-making reduces prescribing (48) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.…”

Section: Main Findings In Comparison With Previous Researchmentioning

confidence: 99%

Risks of use and non-use of antibiotics in primary care. Qualitative study of prescribers’ views

Boiko

Burgess

Fox

et al. 2020

Preprint

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Purpose: The emergence of antimicrobial resistance has led to increasing efforts to reduce unnecessary use of antibiotics in primary care, but potential hazards from bacterial infection continue to cause concern. This study investigated how primary care prescribers evaluate the risks of reduced antibiotic prescribing. Methods: Qualitative study using semi-structured interviews conducted with primary care prescribers from 10 general practices in an urban area and a shire town in England. A thematic analysis was conducted. Results: Thirty participants were recruited, including 23 general practitioners, 5 nurses and 2 pharmacists. Three main themes were identified: risk assessment; balancing treatment risks; and negotiating decisions and risks. Respondents indicated that their decisions were grounded in clinical risk assessment, but this was informed by different approaches to antibiotic use, with most leaning towards reduced prescribing. Prescribers' perceptions of risk included the consequences of both inappropriate prescribing and inappropriate withholding of antibiotics. Sepsis was viewed as the most concerning potential outcome of non-prescribing, leading to possible patient harm and potential litigation. Risks of antibiotic prescribing included antibiotic resistant and C. difficile infections, as well as side effects, such as rashes, that might lead to possible mislabelling as antibiotic allergy. Prescribers elicited patient preferences for use or avoidance of antibiotics to inform management strategies, which included educational advice, advice on self-management including warning signs, use of delayed prescriptions, and safety netting. Conclusions: Attitudes towards antibiotic prescribing are evolving, with reduced antibiotic prescribing now being approached more systematically. The safety trade-offs associated with either use or non-use of antibiotics present difficulties especially when prescribing decisions are inconsistent with patients' expectations.

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Section: Main Findings In Comparison With Previous Researchmentioning

confidence: 99%

Risks of use and non-use of antibiotics in primary care. Qualitative study of prescribers’ views

Boiko

Burgess

Fox

et al. 2020

Preprint

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“…The best evidence is for communication skills training, point-of-care diagnostics and peer-comparison feedback. 31,[34][35][36][37] However, multifaceted strategies targeting both the general public and the prescriber are likely to optimize the impact of community antimicrobial stewardship programs. 38 This study supports the need for a province-wide evidence-based antimicrobial stewardship program, with a strong surveillance component, to improve the appropriate use of outpatient antibiotics and slow the emergence of drug-resistant infections.…”

Section: Openmentioning

confidence: 99%

Regional variability in outpatient antibiotic use in Ontario, Canada: a retrospective cross-sectional study

Schwartz¹,

Achonu²,

Brown³

et al. 2018

cmajo

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Background: Regional variability in antibiotic use is associated with both antibiotic overuse and antimicrobial resistance. Our objectives were to benchmark outpatient antibiotic use and to evaluate geographic variability among health regions in the province of Ontario, Canada. Methods: This was a cross-sectional study of antibiotics dispensed from outpatient retail pharmacies in Ontario between March 2016 and February 2017. We analyzed variability in the number of antibiotic prescriptions dispensed per 1000 population among Ontario's 14 health regions with crude and adjusted Poisson regression models. Adjusted models controlled for rurality, 4 physician characteristics and 6 population characteristics. Results: There were 8 352 578 antibiotics dispensed during the 1-year study period or 621 per 1000 population. The most commonly prescribed antibiotic classes were narrow-spectrum penicillins, macrolides, first-generation cephalosporins and second-generation fluoroquinolones, with adult women receiving the highest rate of prescriptions: 985 antibiotic prescriptions per 1000 population. There was geographic variability in total and class-specific antibiotic use. In the health region with the highest use 778 antibiotics were dispensed per 1000 population whereas in the health region with the lowest use 534 antibiotics were dispensed per 1000 population. The adjusted marginal standardized antibiotic prescription rates for the health regions with the highest and lowest use were 787 (95% confidence interval [CI] 658-934) and 546 (95% CI 494-606) antibiotic prescriptions per 1000 population, respectively. Interpretation: We described baseline antibiotic usage in Ontario over a 12-month period, noting variability among some health regions. Our findings highlight the need for interventions to optimize antibiotic use and slow the emergence of antimicrobial resistance.

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“…6 A recent Cochrane umbrella review of cliniciantargeted interventions to influence antibiotic prescribing concluded that CRP is one of three effective strategies, along with shared decision making and procalcitonin-guided management. 7 However, the latter was only studied in two trials, and in the largest general practice diagnostic study aiming to develop a clinical rule for pneumonia in 3106 patients with cough, procalcitonin did not add any diagnostic information. However, in the same study CRP at the optimal cut-off of 30 mg/L improved the accuracy of a clinical rule based on signs and symptoms.…”

Section: The Impact Of Crp On Antibiotic Prescribing Decisionsmentioning

confidence: 99%

C-reactive protein: guiding antibiotic prescribing decisions at the point of care

Cals

Ebell

2018

Br J Gen Pract

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

Cited by 149 publications

References 74 publications

Risks of use and non-use of antibiotics in primary care. Qualitative study of prescribers’ views

Risks of use and non-use of antibiotics in primary care. Qualitative study of prescribers’ views

Regional variability in outpatient antibiotic use in Ontario, Canada: a retrospective cross-sectional study

C-reactive protein: guiding antibiotic prescribing decisions at the point of care

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