Intervenciones dirigidas a los médicos para influir en la práctica de prescripción de antibióticos para las infecciones respiratorias agudas en la atención primaria: un resumen de las revisiones sistemáticas.
Appendices
Appendix 1. Search strategies
MEDLINE
1 exp Anti‐Bacterial Agents/
2 (Antibacterial? or Anti‐bacterial? or Antibiotic? or Anti‐biotic? or Macrolide? or beta‐Lactam? or Antimicrobial? or Anti‐microbial? or Penicillin or Methicillin or ampicillin or azithromycin or Cephalexin).tw.
3 1 or 2
4 exp Respiratory Tract Infections/ or Nasopharyngitis/ or exp Sinusitis/ or Rhinitis/ or Laryngitis/ or Bronchitis/ or exp bronchiolitis/ or bronchiolitis, viral/ or exp Pneumonia/ or exp Pleurisy/ or Cough/ or Sneezing/ or exp Otitis Media/ or Earache/ or Influenza, Human/ or Common Cold/
5 (((respiratory or chest) adj3 (infect* or inflam*)) or (ARI or ARTI or URTI or LRTI) or (nasopharyngit* or rhinopharyngit*) or sinusit* or (nasosinusit* or rhinosinusit*) or rhinit* or (rhinorrhoea or rhinorrhea) or ((runny or running or discharg* or congest* or blocked or stuff* or dripping) adj2 (nose* or nasal)) or pharyngit* or sore throat* or (throat* adj3 (inflam* or infect*)) or tonsillit* or laryngit* or croup or (pseudocroup or tracheobronchit* or laryngotracheobronchit*) or (bronchit* or bronchiolit*) or (pneumon* or pleuropneumon* or bronchopneumon*) or pleurisy or (cough* or sneez*) or (otitis media or aom or ome) or earache* or (influenza* or flu) or common cold*).tw.
6 4 or 5
7 exp Drug Prescriptions/ or Inappropriate prescribing/ or Practice Patterns, Physicians/
8 (prescrib* or prescrip* or stewardship or Antibiotic therapy or Antibiotic treatment).tw.
9 7 or 8
10 (Delay or Delayed or Reduce or Reduces or Reducing or Reduced or Discontinue or Stopping).tw.
11 Ambulatory Care/ or exp Ambulatory Care Facilities/ or exp general practice/ or exp general practitioners/ or exp physicians, family/ or exp physicians, primary care/ or exp Primary Health Care/ or exp Office Visits/ or Outpatients/ or exp Emergency Service, Hospital/ or Emergency Medical Services/
12 ((ambulatory adj3 (care or setting? or facilit* or ward? or department? or service?)) or (practi* or physician? or doctor? or Clinician?) or (primary care or primary health care or primary healthcare) or (after hour? or afterhour? or "out of hour?" or ooh) or (clinic? or visit?) or ((health* or medical) adj2 (center? or centre?)) or outpatient? or (emergency adj3 (care or setting? or facilit* or ward? or department? or service?))).tw.
13 11 or 12
14 meta‐analysis.mp,pt. or review.pt. or search*.tw.
15 3 and 6 and 9 and 10 and 13 and 14
Embase
1 exp *antibiotic agent/
2 (Antibacterial? or Anti‐bacterial? or Antibiotic? or Anti‐biotic? or Macrolide? or beta‐Lactam? or Antimicrobial? or Anti‐microbial? or Penicillin or Methicillin or ampicillin or azithromycin or Cephalexin).tw.
3 1 or 2
4 exp *respiratory tract infection/ or *ear infection/ or exp *otitis media/ or *coughing/ or *sneezing/ or *otalgia/
5 (((respiratory or chest) adj3 (infect* or inflam*)) or (ARI or ARTI or URTI or LRTI) or (nasopharyngit* or rhinopharyngit*) or sinusit* or (nasosinusit* or rhinosinusit*) or rhinit* or (rhinorrhoea or rhinorrhea) or ((runny or running or discharg* or congest* or blocked or stuff* or dripping) adj2 (nose* or nasal)) or pharyngit* or sore throat* or (throat* adj3 (inflam* or infect*)) or tonsillit* or laryngit* or croup or (pseudocroup or tracheobronchit* or laryngotracheobronchit*) or (bronchit* or bronchiolit*) or (pneumon* or pleuropneumon* or bronchopneumon*) or pleurisy or (cough* or sneez*) or (otitis media or aom or ome) or earache* or (influenza* or flu) or common cold*).tw.
6 4 or 5
7 *prescription/ or inappropriate prescribing/ or *antibiotic therapy/
8 (prescrib* or prescrip* or stewardship or Antibiotic therapy or Antibiotic treatment).tw.
9 7 or 8
10 (Delay or Delayed or Reduce or Reduces or Reducing or Reduced or Discontinue or Stopping).tw.
11 ambulatory care/ or outpatient department/ or outpatient/ or general practice/ or general practitioner/ or primary medical care/ or primary health care/ or emergency ward/ or emergency health service/
12 ((ambulatory adj3 (care or setting? or facilit* or ward? or department? or service?)) or (practi* or physician? or doctor? or Clinician?) or (primary care or primary health care or primary healthcare) or (after hour? or afterhour? or "out of hour?" or ooh) or (clinic? or visit?) or ((health* or medical) adj2 (center? or centre?)) or outpatient? or (emergency adj3 (care or setting? or facilit* or ward? or department? or service?))).tw.
13 11 or 12
14 meta‐analys:.mp. or search:.tw. or review.pt.
15 3 and 6 and 9 and 10 and 13 and 14
CINAHL
1 (MH "Antibiotics+")
2 TI ( Antibacterial? or Anti‐bacterial? or Antibiotic? or Anti‐biotic? or Macrolide? or beta‐Lactam? or Antimicrobial? or Anti‐microbial? or Penicillin or Methicillin or ampicillin or azithromycin or Cephalexin ) OR AB ( Antibacterial? or Anti‐bacterial? or Antibiotic? or Anti‐biotic? or Macrolide? or beta‐Lactam? or Antimicrobial? or Anti‐microbial? or Penicillin or Methicillin or ampicillin or azithromycin or Cephalexin )
3 S1 OR S2
4 (MH "Respiratory Tract Infections+") OR (MH "Otitis Media+") OR (MH "Cough") OR (MH "Sneezing") OR (MH "Earache")
5 TI ( (((respiratory or chest) N3 (infect* or inflam*)) or (ARI or ARTI or URTI or LRTI) or (nasopharyngit* or rhinopharyngit*) or sinusit* or (nasosinusit* or rhinosinusit*) or rhinit* or (rhinorrhoea or rhinorrhea) or ((runny or running or discharg* or congest* or blocked or stuff* or dripping) N2 (nose* or nasal)) or pharyngit* or sore throat* or (throat* N3 (inflam* or infect*)) or tonsillit* or laryngit* or croup or (pseudocroup or tracheobronchit* or laryngotracheobronchit*) or (bronchit* or bronchiolit*) or (pneumon* or pleuropneumon* or bronchopneumon*) or pleurisy or (cough* or sneez*) or (otitis media or aom or ome) or earache* or (influenza* or flu) or common cold*) ) OR AB ( (((respiratory or chest) N3 (infect* or inflam*)) or (ARI or ARTI or URTI or LRTI) or (nasopharyngit* or rhinopharyngit*) or sinusit* or (nasosinusit* or rhinosinusit*) or rhinit* or (rhinorrhoea or rhinorrhea) or ((runny or running or discharg* or congest* or blocked or stuff* or dripping) N2 (nose* or nasal)) or pharyngit* or sore throat* or (throat* N3 (inflam* or infect*)) or tonsillit* or laryngit* or croup or (pseudocroup or tracheobronchit* or laryngotracheobronchit*) or (bronchit* or bronchiolit*) or (pneumon* or pleuropneumon* or bronchopneumon*) or pleurisy or (cough* or sneez*) or (otitis media or aom or ome) or earache* or (influenza* or flu) or common cold*) )
6 S4 OR S5
7 (MH "Prescribing Patterns") OR (MH "Inappropriate Prescribing")
8 TI ( prescrib* or prescrip* or stewardship or "Antibiotic therapy" or "Antibiotic treatment" ) OR AB ( prescrib* or prescrip* or stewardship or "Antibiotic therapy" or "Antibiotic treatment" )
9 S7 OR S8
10 Delay or Delayed or Reduce or Reduces or Reducing or Reduced or Discontinue or Stopping
11 (MH "Ambulatory Care") OR (MM "Ambulatory Care Facilities") OR (MH "Family Practice") OR (MH "Physicians, Family") OR (MH "Physicians, Emergency") OR (MH "Primary Health Care") OR (MH "Emergency Service") OR (MH "Emergency Medicine") OR (MH "Outpatient Service") OR (MH "Outpatients")
12 TI ( ((ambulatory N3 (care or setting? or facilit* or ward? or department? or service?)) or (practi* or physician? or doctor? or Clinician?) or (primary care or primary health care or primary healthcare) or (after hour? or afterhour? or "out of hour?" or ooh) or (clinic? or visit?) or ((health* or medical) N2 (center? or centre?)) or outpatient? or (emergency N3 (care or setting? or facilit* or ward? or department? or service?))) ) OR AB ( ((ambulatory N3 (care or setting? or facilit* or ward? or department? or service?)) or (practi* or physician? or doctor? or Clinician?) or (primary care or primary health care or primary healthcare) or (after hour? or afterhour? or "out of hour?" or ooh) or (clinic? or visit?) or ((health* or medical) N2 (center? or centre?)) or outpatient? or (emergency N3 (care or setting? or facilit* or ward? or department? or service?))) )
13 S11 OR S12
14 S3 AND S6 AND S9 AND S10 AND S13
15 S3 AND S6 AND S9 AND S10 AND S13 ‐ Limiters ‐ Clinical Queries: Review ‐ Best Balance
PsycINFO
1 exp antibiotics/
2 (Antibacterial? or Anti‐bacterial? or Antibiotic? or Anti‐biotic? or Macrolide? or beta‐Lactam? or Antimicrobial? or Anti‐microbial? or Penicillin or Methicillin or ampicillin or azithromycin or Cephalexin).tw.
3 1 or 2
4 exp respiratory tract disorders/ or exp influenza/
5 (((respiratory or chest) adj3 (infect* or inflam*)) or (ARI or ARTI or URTI or LRTI) or (nasopharyngit* or rhinopharyngit*) or sinusit* or (nasosinusit* or rhinosinusit*) or rhinit* or (rhinorrhoea or rhinorrhea) or ((runny or running or discharg* or congest* or blocked or stuff* or dripping) adj2 (nose* or nasal)) or pharyngit* or sore throat* or (throat* adj3 (inflam* or infect*)) or tonsillit* or laryngit* or croup or (pseudocroup or tracheobronchit* or laryngotracheobronchit*) or (bronchit* or bronchiolit*) or (pneumon* or pleuropneumon* or bronchopneumon*) or pleurisy or (cough* or sneez*) or (otitis media or aom or ome) or earache* or (influenza* or flu) or common cold*).tw.
6 4 or 5
7 exp "prescribing (drugs)"/
8 (prescrib* or prescrip* or stewardship or Antibiotic therapy or Antibiotic treatment).tw.
9 7 or 8
10 (Delay or Delayed or Reduce or Reduces or Reducing or Reduced or Discontinue or Stopping).tw.
11 outpatient treatment/ or outpatients/ or exp Primary Health Care/ or exp General Practitioners/
12 ((ambulatory adj3 (care or setting? or facilit* or ward? or department? or service?)) or (practi* or physician? or doctor? or Clinician?) or (primary care or primary health care or primary healthcare) or (after hour? or afterhour? or "out of hour?" or ooh) or (clinic? or visit?) or ((health* or medical) adj2 (center? or centre?)) or outpatient? or (emergency adj3 (care or setting? or facilit* or ward? or department? or service?))).tw.
13 11 or 12
14 (control: or effectiveness or risk:).tw.
15 3 and 6 and 9 and 10 and 13 and 14
Web of Science
1 486,465 TOPIC: (Antibacterial* or Anti‐bacterial* or Antibiotic* or Anti‐biotic* or Macrolide* or beta‐Lactam* or Antimicrobial* or Anti‐microbial* or Penicillin or Methicillin or ampicillin or azithromycin or Cephalexin)
2 415,544 TOPIC: ((((respiratory or chest) NEAR/3 (infect* or inflam*)) or ARI or ARTI or URTI or LRTI or nasopharyngit* or rhinopharyngit* or sinusit* or nasosinusit* or rhinosinusit* or rhinit* or rhinorrhoea or rhinorrhea or ((runny or running or discharg* or congest* or blocked or stuff* or dripping) NEAR/2 (nose* or nasal)) or pharyngit* or "sore throat*" or (throat* NEAR/3 (inflam* or infect*)) or tonsillit* or laryngit* or croup or pseudocroup or tracheobronchit* or laryngotracheobronchit* or bronchit* or bronchiolit* or pneumon* or pleuropneumon* or bronchopneumon* or pleurisy or cough* or sneez* or "otitis media" or aom or ome or earache* or influenza* or flu or "common cold*"))
3 2,388,774 TOPIC: ((ambulatory NEAR/3 (care or setting* or facilit* or ward* or department* or service*)) or practi* or physician* or doctor* or Clinician* or "primary care" or "primary health care" or "primary healthcare" or "after hour*" or afterhour* or "out of hour*" or ooh or clinic or clinics or visit or visits or ((health* or medical) NEAR/2 (center* or centre*)) or outpatient* or (emergency NEAR/3 (care or setting* or facilit* or ward* or department* or service*)))
4 3,612,461 TOPIC: (Delay or Delayed or Reduce or Reduces or Reducing or Reduced or Discontinue or Stopping)
5 225,166 TOPIC: (prescrib* or prescrip* or stewardship or "Antibiotic therapy" or "Antibiotic treatment")
6 169 (#5 AND #4 AND #3 AND #2 AND #1) AND DOCUMENT TYPES: (Review)
7 104,119 (TS=(meta‐analysis OR "systematic review" OR search*)) AND DOCUMENT TYPES: (Review)
8 65 #7 AND #5 AND #4 AND #3 AND #2 AND #1
9 169 #8 OR #6
Appendix 2. Characteristics of reviews awaiting classification
| Review | Included trials (n) | Population | Intervention | Comparison intervention | Primary outcome |
| 13 | Children presenting with upper respiratory infections in primary care | Approaches targeting clinicians or parents of child patients, or both | Usual care | Antibiotic prescribing | |
| (protocol only) | Unknown | Adults and children presenting in primary care with respiratory tract infections | Any intervention aimed at improving the quality of prescribing and use of antibiotics in primary care patients with respiratory tract infections | Unknown | Antibiotic prescribing and use |
| 88 randomised controlled trials | Adult or child patients presenting with acute respiratory tract infections | Any intervention designed to improve antibiotic use aimed at clinicians, patients, or the public | Usual care or alternative intervention | Antibiotic prescribing and use | |
| 2 | Adults or children presenting with acute upper respiratory tract infection in primary care | Written information for patients (or parents of child patients) | Usual care or alternative intervention | Antibiotic prescribing and use |
Appendix 3. Initial ROBIS quality assessment on 11 reviews for potential inclusion in the overview
| Review ID | ROBIS assessment | ||||
| Phase 2 domains | Phase 3 | ||||
| 1. Study eligibility criteria | 2. Identification and selection of studies | 3. Data collection and study appraisal | 4. Synthesis and findings | 5. Risk of bias | |
| Low risk | Low risk | Low risk | Low risk | Low risk | |
| Low risk | Low risk | Low risk | High risk 4.6 ‐ Quality of studies is not assessed in any analysis. | Low risk A. Interpretation of findings addressed all concerns. B. Relevance of identified studies was appropriately considered. C. Review authors avoided emphasising results on the basis of their statistical significance. | |
| Low risk | Low risk | Low risk | High risk 4.6 ‐ Quality of studies is not assessed in any analysis. | Low risk A. Interpretation of findings addressed all concerns. B. Relevance of identified studies was appropriately considered. C. Review authors avoided emphasising results on the basis of their statistical significance. | |
| Low risk | Low risk | Low risk | High risk 4.6 ‐ Quality of studies is not assessed in any analysis. | Low risk A. Interpretation of findings addressed all concerns. B. Relevance of identified studies was appropriately considered. C. Review authors avoided emphasising results on the basis of their statistical significance. | |
| Low risk | Low risk | Low risk | High risk 4.6 ‐ Quality of studies is not assessed in any analysis. | Low risk A. Interpretation of findings addressed all concerns. B. Relevance of identified studies was appropriately considered. C. Review authors avoided emphasising results on the basis of their statistical significance. | |
| Low risk | Low risk | Low risk | Low risk | Low risk | |
| Low risk | Low risk | Low risk | High risk 4.5 ‐ No funnel plots or sensitivity analysis presented. 4.6 ‐ Quality of studies is not assessed in any analysis. | Low risk A. Interpretation of findings addressed all concerns. B. Relevance of identified studies was appropriately considered. C. Review authors avoided emphasising results on the basis of their statistical significance. | |
| High risk 1.5 ‐ Non‐English studies were excluded. | High risk 2.4 ‐ Non‐English studies were excluded. | High risk 3.4 ‐ Review authors provided an assessment of study quality but not 'Risk of bias' assessment. 3.5 ‐ Review authors do not specify which researchers assessed study quality. | High risk 4.5 ‐ No funnel plots or sensitivity analysis presented. 4.6 ‐ Bias in studies is not assessed and not considered in analysis. | High risk A. Review authors do not discuss exclusion of non‐English studies as a limitation. Review authors do not discuss risk of bias or limitations in assessment of study quality. Assessment of study quality is unclear. Review authors do discuss limitations in doing meta‐analysis. B. Relevance of identified studies was appropriately considered. C. Review authors may overemphasise results based on population effect size. | |
| Low risk | Low risk | Low risk | Low risk | Low risk | |
| High risk 1.5 ‐ Non‐English studies were excluded. | High risk 2.2 ‐ No other search methods in addition to databases were used to identify reports. 2.4 ‐ Non‐English studies were excluded. | High risk 3.1 ‐ Review authors do not specify which researchers performed data extraction. 3.5 ‐ Review authors do not specify which researchers performed quality assessment. | High risk 4.6 ‐ Quality of studies is not assessed in any analysis. | High risk A. Review authors do not discuss exclusion of non‐English studies or not using other methods to search for papers as limitations. Review authors did not comment on methods of data extraction or quality assessment as potential limitations. Review authors do discuss 'Risk of bias' assessment. B. Relevance of identified studies was appropriately considered. C. Review authors avoided emphasising results on the basis of their statistical significance. | |
| High risk 1.5 ‐ Search was limited to studies conducted in high‐income countries only, for which a reason was not provided. | High risk 2.1 ‐ Only published studies were included. 2.5 ‐ Only 1 author screened titles and abstracts. | Low risk | High risk 4.6 ‐ Quality of studies is not assessed in any analysis. | High risk A. Review authors acknowledge focus on high‐income countries and published studies in their limitations section. Review authors do not discuss data screening by 1 author. B. Relevance of identified studies was appropriately considered. C. Review authors avoided emphasising results on the basis of their statistical significance. | |
Study flow diagram.
| Intervention | Review | RCTs contributed and sample size (n) | ROBIS assessment | ||||
| Phase 2 domains | Phase 3 | ||||||
| 1. Study eligibility criteria | 2. Identification and selection of studies | 3. Data collection and study appraisal | 4. Synthesis and findings | 5. Risk of bias of review | |||
| POCT: C‐reactive protein | Andreeva 2014 (179) Cals 2009 (431) Cals 2010 (258) Diederichsen 2000 (812) Little 2013 (4264) Melbye 1995 (239) | Low risk | Low risk | Low risk | Low risk | Low risk | |
| Cals 2009 (431) Cals 2010 (258) Cals 2011 (330) Cals 2013* (379) Diederichsen 2000 (812) Gonzales 2011 (131) Melbye 1995 (229) | Low risk | Low risk | Low risk | High risk | Low risk | ||
| POCT: rapid viral detection test | Bonner 2003 (391) Doan 2009 (200) Poehling 2006 (300) | Low risk | Low risk | Low risk | Low risk | Low risk | |
| POCT: procalcitonin | Briel 2008 (458) Burkhardt 2010 (550) Christ‐Crain 2004 (243) Christ‐Crain 2006 (302) Kristoffersen 2009 (210) Long 2009 (127) Long 2011 (156) Schuetz 2009 (1359) Stolz 2007 (208) | Low risk | Low risk | Low risk | Low risk | Low risk | |
| Educational materials for clinician or decision support, or both | Christakis 2001 (NR) Wilson 2002 (NR) | Low risk | Low risk | Low risk | High risk | Low risk | |
| Interventions to support shared decision making | Altiner 2007 (2164) Briel 2006 (552) Butler 2012 (479,502) Cals 2009 (431) Cals 2013* (379) Francis 2009 (558) Légaré 2011 (151) Légaré 2012 (359) Little 2013 (4264) Welschen 2004 (1723) | Low risk | Low risk | Low risk | High risk | Low risk | |
| Patient information leaflets to be used by clinician | Francis 2009 (558) Macfarlane 1997 (1014) | Low risk | Low risk | Low risk | High risk | Low risk | |
| Multifaceted interventions | Finkelstein 2001 (NR) Flottorp 2002 (NR) McIsaac 1998 (NR) McIsaac 2002 (NR) Mainous 2000 (NR) | Low risk | Low risk | Low risk | High risk | Low risk | |
| *Cals 2013 is a follow‐up study of the trial reported in Cals 2009. NR: not reported | |||||||
| Reason for exclusion | Reviews excluded (n = 15) |
| Does not include RCTs including parallel‐group, cluster, or factorial RCTs | |
| Does not include studies that include patients presenting to primary care with acute respiratory infection | |
| Does not include interventions aimed at health professional with the primary goal of reducing antibiotic prescribing | |
| Does not investigate the effect of the intervention on antibiotic prescribing compared to usual care or control | Andrews 2012; Arroll 2003; Rausch 2009; Schuetz 2011; Spurling 2013 |
| Duplication of included review | Schuetz 2013 (duplicate of included Cochrane review Schuetz 2012) |
| Data were not reported at an individual‐study basis. | |
| No novel coverage in addition to included Cochrane Review | Cooke 2015; Engel 2012 (both fully overlap with Aabenhus 2014 in terms of included trials) |
| Rated as high risk in ROBIS quality assessment | |
| RCT: randomised controlled trial | |
| Review | Date assessed as up‐to‐date | Included RCTs (n)* | Population* | Intervention | Comparison intervention | Primary outcome* | Limitations |
| Around January 2014 | 6 | Patients presenting with ARI in general practice | Point‐of‐care tests including C‐reactive protein, procalcitonin, and white blood cell count | Usual care | Number of patients given antibiotic prescription at index consultation and at 28 days' follow‐up | Small number of included studies | |
| December 2002 | 5 | Patients presenting with RTI in primary care | Professional interventions in the Cochrane Effective Practice and Organisation of Care Group. To include: education materials for clinician, educational meetings, local consensus processes, educational outreach visits, local opinion leaders, patient‐mediated interventions, audit and feedback, reminders, marketing, mass media, financial interventions | Usual care or other intervention | Decision to prescribe an antibiotic or not | None reported. | |
| February 2009 | 2 | Children presenting with URTI in primary care | Computerised evidence‐based decision support, development of clinical practice guidelines, and educational materials for clinician | Usual care | Antibiotic prescribing and reduced proportion of prescribed antibiotic courses | Potential for publication bias in search. Cost‐effectiveness not evaluated. Insufficient information to judge risk of bias in some areas | |
| December 2014 | 9 (reported in 10 papers) | Patients presenting with ARI in primary care | Shared decision making | Usual care or other intervention | Prescription of antibiotics | Intraclass correlation was imputed for 2 studies. | |
| April 2014 | 2 | Patients presenting with ARI in general practice | Patient information leaflets (PIL) for use by clinicians in consultations | No PIL | Antibiotic prescribing | Studies were at high risk of bias as blinding to the intervention was not possible. Patients included and outcomes assessed were diverse. No heterogeneity analysis was conducted. | |
| Around July 2014 | 3 | Children presenting with ARI in the emergency department | Rapid viral diagnosis by testing | No test or test result not made known to clinician | Antibiotic prescribing rate | None reported. | |
| June 2013 | 6 (reported in 7 papers) | Patients presenting with ARI in general practice | C‐reactive protein point‐of‐care test | No test or usual care, or both | Antibiotic prescribing at index consultation | Meta‐analysis is based on aggregate data rather than individual‐participant data, so difficult to explore sources of heterogeneity. | |
| 2011 | 9 | Adults presenting with ARI in primary care | Strategies to initiate or discontinue antibiotic therapy based on procalcitonin cut‐off ranges | No use of procalcitonin | Initiation of antibiotics | Variation in patient populations/settings and treatment failure was defined differently for each context. | |
| *relevant to this overview | |||||||
| Review ID | Random sequence generation | Allocation concealment | Blinding of participants | Blinding of outcome assessment | Incomplete outcome data | Selective reporting | Other bias |
| (6 RCTs) | 5 studies* (83%1) | 1 study (17%) | None (0%) | 5 studies*2 (83%) | 6 studies (100%) | 4 studies (67%) | 1 study (17%) |
| (5 RCTs) | Not reported | 1 study (20%) | Not reported | 3 studies (60%) | 2 studies (20%) | Not reported | Not reported |
| (2 RCTs) | 2 studies (100%) | 1 study (50%) | 2 studies (100%) | 2 studies (100%) | 2 studies (100%) | 2 studies (100%) | 1 study (34%) |
| (10 RCTs2) | 10 studies (100%) | 7 studies (70%) | 1 study (10%) | 7 studies (70%) | 9 studies (90%) | 10 studies (100%) | 7 studies (70%) |
| (2 RCTs) | 1 study (50%) | 2 studies (100%) | None (0%) | 1 study (50%) | 2 studies (100%) | 2 studies (100%) | Not reported |
| (3 RCTs) | 3 studies (100%) | 1 study (34%) | None (0%) | None (0%) | 2 studies (67%) | 3 studies (100%) | 3 studies (100%) |
| (7 studies3) | 1 study* (14%) | 1 study (14%) | None (0%) | None* (0%) | 5 studies (71%) | 7 studies (100%) | None (0%) |
| (9 RCTs) | 7 studies (78%) | 4 studies (33%) | None (0%) | 4 studies (33%) | 9 studies (100%) | 9 studies (100%) | 3 studies (43%) |
| RCT: randomised controlled trial | |||||||
| *Results differ between reviews where RCTs had significant overlap. Aabenhus 2014 provided more detailed reporting of risk of bias than Huang 2013. | |||||||
| Interventions to reduce antibiotic prescribing in the management of acute respiratory infections for patients presenting in primary care | |||||||
| Outcome | Intervention and comparison intervention | Contributing reviews | Relative effect (95% CI) of an antibiotic being prescribed1 | Number of participants (RCTs) | Quality of the evidence (GRADE)* | Comments | |
| Change in antibiotic prescriptions for ARI (at consultation) | CRP point‐of‐care test / usual care | RR 0.78 (0.66 to 0.92) | 3284 (6) | Moderate6 | CRP point‐of‐care testing probably reduces antibiotic prescribing in general practice compared to usual care. However, CRP testing may have little or no effect on prescribing in emergency departments. | ||
| General practice setting (individual trials reported): RR 0.57 (0.44 to 0.74) RR 0.58 (0.45 to 0.74) Emergency department setting: RR 1.23 (0.76 to 1.99) | 330 (1) 379 (1) 131 (1) | Moderate3* Low3,6* | |||||
| Rapid viral diagnosis / usual care | RR 0.86 (0.61 to 1.22) | 891 (3) | Low3,6* | Rapid viral diagnosis may have little or no effect on antibiotic prescribing compared to usual care. | |||
| Procalcitonin‐guided management / usual care | General practice setting: adjusted OR 0.10 (0.07 to 0.14) Emergency department setting: adjusted OR 0.34 (0.28 to 0.43) | 1008 (2) 2605 (7) | Moderate3 Moderate3 | Procalcitonin‐guided management probably reduces antibiotic prescribing in general practice and the emergency department compared to usual care. | |||
| Clinician education and decision support / usual care | Difference in behaviour change ‐12% (0.095) OR 0.60 (0.43 to 0.83) | Not reported (1) Not reported (1) | Very low3,5,6* | We are uncertain about whether clinician education and decision support reduces antibiotic prescribing compared to usual care. | |||
| Patient information leaflets / usual care | RR 0.47 (0.36 to 0.64) RR 1.15 (0.89 to 1.48) | 558 (1) 1014 (1) | Very low3,4,6* | We are uncertain as to whether patient information leaflets reduce antibiotic prescribing compared to usual care. | |||
| Shared decision making / usual care | No pooled analysis of all trials: OR 0.44 (0.26 to 0.75) RR 0.64 (0.49 to 0.84) adjusted risk difference ‐18.44 (‐27.24 to ‐9.65) | 3274 (3) 4623 (2) 481,807 (4) | Moderate3 | Shared decision making probably reduces antibiotic prescribing compared to usual care. | |||
| Multifaceted interventions | |||||||
| Printed educational materials for clinicians and reminders / usual care | Individual trials reported: OR 0.44 (0.21 to 0.92) OR 0.57 (0.27 to 1.17) | Not reported (1) Not reported (1) | Very low3,4,6* | We are uncertain as to whether printed educational materials reduce antibiotic prescribing compared to usual care. | |||
| Audit and feedback (with patient education materials) / usual care | Difference in behaviour change: ‐7.3% (audit and feedback alone) Difference in behaviour change: ‐7.2% (audit and feedback with patient materials) | Not reported (1) | Low3,6* | Audit and feedback may reduce antibiotic prescribing compared to usual care. | |||
| Educational materials and educational meetings for clinician and patient education materials / usual care | Difference in behaviour change: 16% (8% to 23%) (age 3 to 36 months) Difference in behaviour change: 12% (2% to 21%) (age 36 to 72 months) | Not reported (1) | Low3,6* | Educational materials and meetings may reduce antibiotic prescribing compared to usual care. | |||
| Educational materials, computerised decision support, professional development, financial incentive, and patient education materials / usual care | Difference in behaviour change: ‐3.0% (P = 0.03) | Not reported (1) | Low3,6* | These interventions may slightly reduce antibiotic prescribing compared to usual care. | |||
| Change in antibiotic prescriptions for ARI (within 28 days of consultation) | CRP point‐of‐care test / usual care | RR 0.80 (0.67 to 0.96) | 3284 (6) | Moderate6 | CRP point‐of‐care testing probably reduces antibiotic prescribing for up to 28 days following consultation compared to usual care. | ||
| Adverse events | CRP point‐of‐care test / usual care | RR 2.45 (0.65 to 9.19) | 4264 (1) | Moderate6 | CRP point‐of‐care testing probably results in little or no difference in adverse events compared to usual care. | ||
| Symptom duration or severity | CRP point‐of‐care test / usual care | At 7 days: RR 1.03 (0.93 to 1.14) At 28 days: RR 0.94 (0.69 to 1.28) | 1309 (3) 849 (3) | Moderate6 | CRP point‐of‐care testing probably results in little or no difference in symptom duration or severity compared to usual care. | ||
| Health‐related quality of life | Procalcitonin‐guided management / usual care | Adjusted difference in days 0.05, ‐0.46 to 0.56, P = 0.854 | 1008 (2) | Moderate3 | Procalcitonin‐guided management probably results in little or no difference in health‐related quality of life compared to usual care. | ||
| Patient satisfaction | CRP point‐of‐care test / usual care | RR 0.79 (0.57 to 1.08) | 689 (2) | Moderate6 | CRP point‐of‐care testing probably results in little or no difference in patient satisfaction compared to usual care. | ||
| Shared decision making / usual care | RR 0.86 (0.57 to 1.30) | 1110 (2) | Low3,6 | Shared decision making may result in little or no difference in patient satisfaction compared to usual care. | |||
| Management failure – reconsultation and treatment failure | CRP point‐of‐care test / usual care | RR 1.08 (0.93 to 1.27) | 5132 (4) | Moderate6 | CRP point‐of‐care testing probably results in little or no difference in reconsultation compared with usual care at 28 days' follow‐up. | ||
| Shared decision making / usual care | RR 0.87 (0.74 to 1.03) | 1860 (4) | Moderate3 | Shared decision making probably results in little or no difference in reconsultation compared to usual care. | |||
| Patient information leaflets / usual care | Individual trials reported: RR 0.80 (0.52 to 1.21) RR 0.70 (0.53 to 0.91) | 558 (1) 1014 (1) | Very low3,4,6* | We are uncertain as to whether patient intervention leaflets result in a difference in reconsultation compared to usual care. | |||
| Rapid viral diagnosis / usual care | RR 0.86 (0.59 to 1.25) | 200 (1) | Low3,6* | Rapid viral diagnostics may result in little or no difference in reconsultation relative to usual care. | |||
| Procalcitonin‐guided management / usual care | Treatment failure in general practice2: adjusted OR 0.95 (0.73 to 1.24) Treatment failure in emergency department2: adjusted OR 0.76 (0.61 to 0.95) | 1008 (2) 2605 (7) | Moderate3 | Procalcitonin‐guided management probably results in little or no difference in treatment failure in general practice compared to normal care. Procalcitonin‐guided management probably reduces treatment failure in the emergency department compared to usual care. | |||
| GRADE quality of evidence and definitions High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: Any estimate of effect is very uncertain. *GRADE criteria were applied retrospectively to outcomes when GRADE was not used by the original review authors. ARI: acute respiratory infection; CI: confidence interval; CRP: C‐reactive protein; OR: odds ratio; RCT: randomised controlled trial; RR: risk ratio | |||||||
| 1Effect estimates are shown as reported in the original reviews. Multiple effect estimates are reported for some outcomes when reviews did not pool data from trials but reported individual trials separately. | |||||||
