Interventions with Evidence of Improved or Reduced Antibiotic Prescribing and No, Insufficient, or Mixed Evidence on Adverse Consequences:

Streptococcal Antigen Testing, Rapid Viral Testing

Compared with usual care, large reductions in prescribing (20–52%) were seen when rapid strep testing for sore throat was used (moderate strength), with some evidence pointing to reductions in inappropriate prescribing (low strength).  No evidence was available for other outcomes such as return visits. Similarly, multiviral PCR testing improved prescribing outcomes (low strength) but no evidence on adverse consequences could be inferred.

Communication Training

Interventions focused on better communication from clinicians to patients regarding antibiotic use for RTIs resulted in a reduction of prescriptions (<10% to >25%), in the five randomized trials that investigated this approach (moderate strength). However, there was no clear evidence on symptom improvement, with three of the studies showing a slightly longer duration of symptoms (low strength). There was insufficient evidence to assess reconsultations, patient satisfaction, or hospitalizations.

Delayed Prescribing

Delayed versus immediate prescribing reduced prescriptions by 34–76% (moderate strength), however there was no evidence available for improvements in appropriate prescribing. Delayed prescribing was also associated with reduced patient satisfaction (moderate strength), reduced antibiotic resistance and diarrhea in AOM (low strength), and increased persistence of moderate to severe symptoms (low strength); there was no difference seen in reconsultation.

C-Reactive Protein

CRP tests showed a reduction in overall prescription rates for RTIs (1.9–33.5%), though these reductions varied greatly depending on the baseline-prescribing rate (moderate strength). Reconsultations within 4 weeks also increased with the CRP test method (moderate strength). A potentially increased risk of hospitalization at 30 days was also noted (low strength). There was no effect on symptom resolution or use of chest x-rays (low strength).

Combined Interventions

Clinician communication training combined with CRP testing showed a large reduction in overall prescriptions of >25%, compared with usual care. One RCT which used the combined interventions method and included 4,000 patients, showed no impact on reconsultation, diagnostic testing use, or days off work. However, the number of hospitalizations at 1 month was slightly increased for the interventions group (1.1% vs. 0.2%). The authors could not come to a clear understanding for this increase.