Action

• Watchful waiting/observation therapy with no prescription or with a delayed antibiotic prescription

Outcomes

• Antibiotic use for AOM at 3 days (primary) and 7–10 days (secondary)

• Parental visit satisfaction

• Prospective randomized trial

Participants

• Children aged 2 to 12 years diagnosed with AOM and who met criteria for observation

Setting

• Pediatric emergency department of an urban public hospital in the United States (New York)

• At 3 days: 87% parents of children in the observation group with no antibiotic prescription reported no antibiotic use versus 62% parents of children in the of children in the observation group with a delayed antibiotic prescription.

• At 7–10 days, 81% of the observation group with no antibiotic prescription reported no use of antibiotics compared with 53% in the group with a delayed antibiotic prescription.

• No differences in satisfaction were observed between the groups.

• Observation without an antibiotic prescription led to lower antibiotic use for AOM than observation with a delayed antibiotic prescription without affecting visit satisfaction.

4 antibiotic prescriptions strategies for acute uncomplicated respiratory tract infections.

o Delayed antibiotic prescription given to patients at the visit with instructions to wait to fill it unless not improving

o Delayed antibiotic prescription awaiting patient at clinic, patient to return and collect prescriptions if not improving

o Immediate antibiotic prescription issued at visit

o No antibiotic prescription issued at visit

Outcomes

• Primary: symptom duration and severity

• Secondary: antibiotic use, patient satisfaction, and belief about antibiotic effectiveness among patients complicated respiratory infections.

• Open-label, randomized clinical trial

Participants

• Adults with acute, uncomplicated respiratory infections

Setting

• 23 primary care clinics in Spain

• Delayed prescription strategies led to lower antibiotic use:

o 91% of patients used antibiotics in the immediate prescription group;

o 33% of patients used antibiotics in the group with delayed prescription;

o 23% of patients used antibiotics in the group who had to collect the delayed prescription;

o 12% of patients used antibiotics in the no prescription group.

• Delayed and no prescription strategies led to “slightly greater” symptom burden.

• Similar satisfaction was observed among groups.

• No intervention; observational study

Outcomes

• Rates of delayed antibiotic prescribing in adults presenting with acute cough to primary care.

• Duration of advised delay

• Consumption of delayed antibiotic or another antibiotic at 28 days

• Factors associated with antibiotic consumption

• Prospective observational cohort study

Participants

• General practitioners

• Adult patients with acute cough

Setting

• 14 primary care networks in 13 European countries

• About 6% (n = 210) were prescribed delayed antibiotics (median recommended delay 3 days).

• 44% (n = 75/169) with consumption data used the delayed prescription antibiotic course by 28 days

• 30% (n = 50/169) started on the day the prescription was written.

• 10% took another antibiotic by 28 days.

• 45% took no antibiotic by 28 days. Upper respiratory tract/viral infections diagnoses were associated with lower use of delayed prescription.

• Patients who wanted antibiotics were more likely to consume the antibiotics.

• Expanding delayed antibiotic prescribing and standardizing prescribing practices may improve antibiotic prescribing.

• One of 3 prescribing strategies was used

• Immediate antibiotics

• No antibiotics

• Delayed antibiotics available by request after 14 days

• Information leaflet for acute lower respiratory tract infection

Outcomes

• Clinical signs and symptoms

• Reported antibiotic use

• Daily diary and satisfaction questionnaire

• Randomized controlled trial

• Factorial design involving 6 groups: leaflet or no leaflet and 1 of 3 prescribing strategies

Participants

• 37 English general practitioners

• Patients aged ≥3 years with acute uncomplicated lower respiratory infections

Setting

• Primary care clinics in England

• No implemented intervention altered cough duration or other clinical outcome.

• Cough lasted on average 11.7 days.

• The information leaflet did not have any impact on main outcome.

• Fewer patients in the delayed and control groups, compared with immediate antibiotic group, used antibiotics, were “very satisfied” with visit, and believed in the antibiotic effectiveness.

Brit Med J 2014. 348:g1606.

• Delayed antibiotic prescribing strategies

o Re-contact for a prescription (i.e., patient calls for the prescription)

o Post-dated prescription

o Post-visit collection of a prescription

• No antibiotic prescription

Outcome

• Primary: Symptom severity at days 2–4

• Secondary: antibiotic use by 14 days and patient belief about antibiotic effectiveness

• Open, pragmatic, randomized controlled trial

Participants

• Patients aged ≥3 years with acute respiratory tract infections

Setting

• 25 primary care clinics in the United Kingdom

• No significant differences in symptom severity were observed between those who received no prescription and those receiving delayed prescription via any strategy.

• Symptom duration did not differ between groups, and no significant difference was observed for patient satisfaction.

• Those receiving antibiotics did not appear to benefit from them based on symptom severity scores.

• Interventions involving delayed prescriptions or no prescriptions were associated with less belief in antibiotic efficacy and similar symptom outcomes compared with immediate antibiotic prescriptions.

• Watchful waiting (WW) versus immediate antibiotic prescription

• Educational intervention

Outcome

• Patient satisfaction with care

• Resolution of symptoms

• Acute otitis media (AOM) failure/recurrence

• Nasopharyngeal colonization with antibiotic-resistant Streptococcus pneumoniae

• Single-blind, randomized controlled trial (investigators were blinded)

Participants

• Children aged 6 months to 12 years with nonsevere AOM

Setting

• Pediatric clinics in in the United States (Texas)

• Parent satisfaction with care did not differ between treatment groups.

• Children treated with immediate antibiotics had faster symptom resolution.

• In the WW group, 66% of children did not take antibiotics by day 30.

• The WW group were reduced by 73% compared with the immediate antibiotic group.

• Immediate antibiotic treatment group had more antibiotic adverse drug events than WW group.

• Children in the immediate antibiotic group were more likely to have multi-drug resistant S. pneumoniae nasopharyngeal colonization at day 12.

• Classification of AOM severity, parent education, symptom management, followup care, and access to effective antibiotics when needed are all important in implementing watchful waiting for children with AOM.

• Delayed antibiotic prescription (“safety-net prescription”)

Outcomes

• Primary: parental willingness to treat AOM without antibiotics and with pain medicine alone

• Secondary: filling of antibiotic prescription, parents’ future plans to use antibiotics for AOM

• Cohort study

Participants

• Children aged 1 to 12 years with nonsevere AOM

Setting

• 11 pediatric clinics in the United States

• At follow-up, 31% of parents had filled the antibiotic prescription.

• 63% of parents reported willingness in future to use pain medicine only without antibiotics for AOM.

• “Wait and see” (i.e., delayed) antibiotic prescription versus standard prescription for children with acute otitis media (AOM)

Outcomes

• Filling of the antibiotic prescription

• Clinical symptoms and symptoms resolution

• Randomized controlled trial

Participants

• Children aged 6 months to 12 years with AOM

Setting

• Emergency department in Northeastern United States

• More parents in the wait and see group did not fill the antibiotic prescription (62%) compared with the standard prescription group (13% did not fill antibiotic prescription, p<0.001).

• No differences between groups were observed for the frequency of fever, ear pain, or unscheduled medical visits.

• In the wait and see group, fever and ear pain were associated with filling the antibiotic prescription.

• Internet based training on communication skills, C-reactive protein (CRP) testing, or both versus standard care

Outcome

• Changes in antibiotic prescribing for respiratory tract infections (RTIs)

• Cluster randomized controlled trial

Participants

• Primary care providers

Settings

• 246 primary care clinics in 6 European countries

• Training in CRP testing and communication skills independently led to reductions in antibiotic prescribing for RTIs, and combination of both trainings led to largest reduction.

• Physician enhanced communication skills training

• Point-of-care C-reactive protein (CRP)

Outcome

• Patient visits for respiratory tract infections (RTIs)

• Percent of RTI episodes treated with antibiotics

• Pragmatic, cluster-randomized controlled trial

• 3.5 years of follow-up

Participants

• Patients with family physician visits for RTIs

Setting

• 20 family practices in the Netherlands

• No difference in number of patient visits for RTIs among groups.

• RTI episodes treated by physicians who received communications training were less likely to receive antibiotics in follow-up period (26% with communications training v. 39% control, p = 0.02).

• No difference in antibiotic treatment during follow-up for RTI episodes in CRP group.

• Suggested alternatives to antibiotics placed within electronic health records for these diagnoses

• Accountable justification required in medical record for non-recommended antibiotic prescribing

• Peer comparison to top-performing peers

Outcomes

• Rate of antibiotic prescribing for acute respiratory tract infections for which antibiotics are not indicated

• Cluster randomized clinical trial

Participants

• 248 primary care clinicians

Settings

• 47 primary care practices in the United States

o 14,753 during baseline

o 16,959 during intervention

• Antibiotic prescribing decreased from:

o Controls: 24.1% to 13.1%

o Suggested alternatives: 22.1% to 6.1% (p = 0.66 for differences compared with control group)

o Accountable justification: 23.2% to 5.2% (p<0.001)

o Peer comparison: 9.9% to 3.7 (p<0.001).

• Compared with the control group, no intervention showed significant diagnosis shifting.

• Clinical decision support involving integration of Walsh rule for streptococcal sore throat and Heckerling rule for pneumonia

Outcomes

• Frequency of antibiotic prescriptions and streptococcal tests in experimental versus control group

• Use of clinical prediction rule in EHR

• Randomized clinical trial

Participants

• Attending physicians, fellows, residents and nurse practitioners

• Patients with complaints consistent with pharyngitis or pneumonia

Setting

• Two large urban ambulatory care practices in the United States (New York)

• Clinicians in the intervention group used the clinical prediction rules in 58% of visits.

• Intervention clinicians were less likely to prescribe antibiotics than control clinicians (RR = 0.75; 95% CI, 0.60–0.92).

• Number needed to treat to prevent one antibiotic prescription was 10.8.

• Intervention clinicians ordered rapid streptococcal tests for patients with pharyngitis less often than control clinicians (RR 0.75; 95% CI, 0.58–0.97).

• Clinical decision support targeting antibiotic prescribing for common conditions

• Patient education materials

Outcomes

• Change in antibiotic prescribing over time for non-pneumonia acute respiratory infections (ARIs)

• Change over time in broad-spectrum antibiotic prescriptions for ARIs

• Quasi-experimental study

Participants

• Clinicians working in primary care clinics

Setting

• Primary care clinics in the United States (Colorado), including adult and pediatric clinics; urban, suburban and rural clinics; academic and private providers

• Antibiotic prescriptions for visits for non-pneumonia ARIs decreased from 42.7% to 37.9% (11.2% relative reduction) in the intervention group compared with 39.8% to 38.7% in the control group (2.8% relative reduction) during the intervention period.

• Use of broad-spectrum antibiotics decreased from 26.4% to 22.6% in the intervention group (14.4% relative reduction) compared with a 20.0% to 19.4% reduction in the control group (3.0% relative reduction).

• Clinical decision support, through the electronic medical record, or printed tools targeting antibiotic prescribing for acute bronchitis

• Clinician and patient education

• Audit and feedback

• Controls without interventions

Outcomes

• Reductions in antibiotic prescribing for acute uncomplicated bronchitis.

• Cluster randomized controlled trial

Participants

• Primary care clinicians

Setting

• 33 primary care practices in the United States (Pennsylvania)

• Prescribing for acute bronchitis reduced by 11.7% in the print-based strategy and 13.7% in the EMR-based strategy.

• Prescribing at control sites increased slightly.

• The observed effect in print-based versus computer-based interventions showed no significant differences.

• Clinical decision support promoting adherence to clinical practice guidelines for acute respiratory infections (ARIs)

Outcomes

• Guideline concordance and proportion of inappropriate antibiotic prescribing

• Reductions in fluoroquinolone and azithromycin use

• Non-randomized retrospective controlled study

Participants

• Primary care providers for an outpatient veteran population

Setting

• Outpatient clinics in a veteran’s healthcare system in the United States

• Clinical decision support was associated with greater clinical practice guideline adherence (RR = 2.57 95% CI, 1.87 to 3.54).

• Inappropriate prescriptions for fluoroquinolones and azithromycin decreased from 22% to 3% (p<0.0001).

• Electronic health record-based clinical decision support for acute respiratory infection (ARI) — “ARI Smart Form” versus standard care

Outcome

• Antibiotic prescribing for acute respiratory tract infections

• Randomized controlled trial

Participants

• Primary care providers

Setting

• 27 primary care clinics in the United States (Massachusetts)

• ARI Smart Form only used in 6% of eligible visits.

• Antibiotic prescribing for intervention clinics was not different compared with controls: odds ratio (OR) 0.8; 95% CI 0.6–1.2.

• When ARI Smart Form was used (per protocol analysis), ARI prescribing was modestly improved.

• Clinical decision support (CDS) in an electronic health record system

• Audit and feedback to clinicians with peer comparison

Outcome

• Physician guideline adherence for management of acute otitis media (AOM) and otitis media with effusion (OME)

• Factorial-design cluster randomized trial

Participants

• Primary care providers

Setting

• Primary care network in the United States (Pennsylvania, New Jersey, and Delaware)

• Guidelines were adhered to in 15% and 5% of AOM and OME cases, respectively during the baseline period.

• Improvements in guideline adherence was larger in visits with CDS and audit and feedback

• Audit and feedback combined with CDS did not improve guideline adherence beyond levels observed for audit and feedback alone.

• The effect of the individual interventions did not appear to be additive.

• Use of a nursing advice hotline to optimize self-care for upper respiratory infections

Outcomes

• Clinical outcomes associated with related cases

• Sufficiency of advice as evidence by no return calls within 7 days leading to a “higher” level of care, such as an in-person appointment.

• Retrospective observational study

Participants

• Adult patients 18 years and older who called into a self-care advice line for URI symptoms

Setting

• Large healthcare system in the United States (California)

• For 88% of initial advice calls, self-care advice over the phone alone was sufficient.

• Most follow-up calls made by the patient were for additional advice or other information.