Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections

Abstract

Antibiotic use is a modifiable driver of antibiotic resistance. In many circumstances, antibiotic use is overly broad or unnecessary. We systematically assessed factors associated with antibiotic prescribing for respiratory tract infections (RTI). Studies were included if they used actual (not self-reported or intended) prescribing data, assessed factors associated with antibiotic prescribing for RTIs, and performed multivariable analysis of associations. We searched Medline, Embase, and International Pharmaceutical Abstracts using keyword and MeSH (medical subject headings) search terms. Two authors reviewed each abstract and independently appraised all included texts. Data on factors affecting antibiotic prescribing were extracted. Our searches retrieved a total of 2,848 abstracts, with 97 included in full-text review and 28 meeting full inclusion criteria. Compared to other factors, diagnosis of acute bronchitis was associated with increased antibiotic prescribing (range of adjusted odds ratios [aOR], 1.56 to 15.9). Features on physical exam, such as fever, purulent sputum, abnormal respiratory exam, and tonsillar exudate, were also associated with higher odds of antibiotic prescribing. Patient desire for an antibiotic was not associated or was modestly associated with prescription (range of aORs, 0.61 to 9.87), in contrast to physician perception of patient desire for antibiotics, which showed a stronger association (range of aORs, 2.11 to 23.3). Physician's perception of patient desire for antibiotics was strongly associated with antibiotic prescribing. Antimicrobial stewardship programs should continue to expand in the outpatient setting and should emphasize clear and direct communication between patients and physicians, as well as signs and symptoms that do and do not predict bacterial etiology of upper respiratory tract infections.T he rapid and ongoing spread of antimicrobial-resistant organisms threatens our ability to successfully treat a growing number of infectious diseases (1, 2). It is well established that antibiotic use is a significant, and modifiable, driver of antibiotic resistance (3-5), and that antibiotics are often misused (6). In settings where a prescription is required to access antibiotics, the prescriber-patient encounter is a logical target for improving appropriate use.Despite the importance of the topic, there is no existing systematic review to identify drivers of antibiotic prescribing from real prescription data. A narrative review of factors influencing antibiotic prescribing highlighted the multiple sources of influence affecting a potential prescribing encounter, including factors related to the prescribing physician (e.g., fear of failure, diagnostic uncertainty, or inadequate training), the patient (e.g., a high-risk or vulnerable patient history), and the environment (e.g., regulation of pharmaceutical prescribing and dispensing and lack of resources for etiological diagnosis) (7). Another study systematically reviewed reasons for inappropriate antibiotic prescriptions, f...

Patient expectation trends on receiving antibiotic prescriptions for respiratory tract infections: A systematic review and meta‐regression analysis

“…Our research is focused on patient expectation for receiving antibiotics for RTIs, of which most are viral infections not requiring antibiotics. Inappropriate antibiotic prescribing for RTIs can lead to over‐prescribing and contribute to antimicrobial resistance . To understand this behaviour, it is essential to identify the contributing components in the prescribing process.…”

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

“…Despite URTIs generally being minor illnesses, they result in an appreciable number of medical consultations globally 87,[199][200][201][202][203] . The number of healthcare consultations combined with parental and patient pressure increases antibiotic use for URTIs including LMICs thereby increasing AMR rates 88,153,200,[204][205][206][207][208][209] . Patients or parents who are concerned about their or their child's respiratory illness are likely to seek treatment, and want an antibiotic, especially if they perceive the illness as severe 21,209,210 .…”

“…Education initiatives for doctors starting at medical school may be necessary in LMICs where there are concerns with current training and its impact on reducing inappropriate prescribing of antibiotics 48,50,315,[319][320][321][322][323][324][325][326][327] . Improving communication between family doctors and patients should help address concerns that physicians want to help their patients, and tend to overestimate patients' expectations regarding their wish to be prescribed an antibiotic for their URTI 21,153,156 . Physicians are also more likely to prescribe an antibiotic if they feel under pressure 108,328,329 .…”

“…We are aware that an appreciable number of publications and ongoing research already exist discussing potential ways to improve antibiotic utilization especially in LMICs, which includes improved surveillance 29,45,61,66,85,100,119,120,151,152 . A number of systematic reviews regarding the management of URTIs and ways to improve both the prescribing and dispensing of antibiotics for patients with URTIs have also been published 21,43,45,57,61,74,85,108,153,154 . These include systematic reviews determining possible reasons behind dispensing antibiotics without a prescription 141,155 , patient-related determinants regarding antibiotic use 156 , and reviews assessing the influence of targeted communications among patients to reduce excessive antibiotic use 157 .…”

Antibiotic prescribing for acute respiratory tract infections in Norwegian primary care out-of-hours service

“…A systematic review on antibiotic prescribing for respiratory tract infections, found that acute bronchitis and features on physical exam were factors associated with antibiotic prescribing [10]. Physician’s perception of patient desire for antibiotics was a stronger prediction for prescription than patient desire for an antibiotic.…”