Interventions with Evidence of No Effect on Antibiotic Prescribing

The authors found that clinic-based education for parents of children 24 months of age or younger with AOM had no effect on overall prescribing (moderate strength). Overall prescribing was also found to be unchanged with clinician education combined with audit and feedback (low strength), point-of-care testing for influenza in children (moderate strength), and tympanometry point-of-care testing in children (low strength). The findings for influenza testing were not surprising given that most tests were likely conducted to confirm suspected viral illness.

Interventions with Evidence of a Negative Effect on Antibiotic Prescribing

An increase in adverse events, in addition to an increase in antibiotic prescribing, was noted among children when the adult algorithm for procalcitonin was used. This research suggests that procalcitonin should not be employed for guiding antibiotic prescribing in children until further studies on safety and efficacy can be conducted.

Implications for Clinical Practice:

Although the best evidence supports four interventions (clinic-based and public campaign educational interventions, procalcitonin testing, electronic decision support systems) out of all the interventions mentioned, it is important to note that benefits are likely to vary depending on situation and that clinicians will need to make intervention choices taking into account the characteristics of the setting in which they will be applied. Patient education can be simple, such as a waiting room poster or a letter from a local clinician. Electronic decision support systems can be implemented into electronic medical record systems. Ease of use of this program is important as it will dictate how often it will be used. While in some cases regular viral testing is appropriate, such as with rapid strep testing, the evidence does not support regular viral testing as a way to improve antibiotic prescribing. Procalcitonin was the only point-of-care test with evidence of benefit without increased adverse consequences in adults, however use of this method actually increased antibiotic prescribing in children. 

Conclusion:

The findings of this Healthcare Research and Quality review are vital in providing groundwork for further research. The authors call for “future studies to use a complex intervention framework and better evaluate measures of appropriate prescribing, adverse consequences such as hospitalization, sustainability, resource use, and the impact of potential effect modifiers.”

References:

1.     Kavanagh KT. How I was prescribed an unnecessary antibiotic while traveling to a conference on antibiotice resistance. JAMA Intern Med. 2014 Sep; 174(9):1433-4.

2.     Center for Disease Dynamics Economics and Policy. ResistanceMap: Outpatient Antibiotic Use. www.cddep.org. Accessed on Feb 26, 2015.