Interventions to Influence the Use of Antibiotics for Acute Upper Respiratory Tract Infections

ABSTRACT

Acute upper respiratory tract infections (URTIs) result from viral or bacterial pathogens that infect the upper airways.1 URTIs comprise a range of conditions and symptoms such as cough, sore throat, acute otitis media (AOM), pharyngitis, tonsillitis, rhinitis, common cold, influenza, and sinusitis.1 While serious complications are rare, patients can develop pneumonia and associated adverse sequelae.1 A substantial proportion of health care visits to primary care and other family medicine settings are due to suspected URTIs.2 Most URTIs are viral in origin, meaning they are unlikely to benefit from antibiotics and can often be effectively managed remotely with supportive treatments. Despite this knowledge, antibiotics are often inappropriately prescribed.3 , 4 A descriptive analysis in Ontario estimated unnecessary antibiotic prescribing in primary care at rates of 48.4% for acute sinusitis and 52.6% for acute bronchitis.5 Further, more than 80% of unnecessary antibiotic prescriptions were attributed to respiratory tract conditions and infections.5 Overprescribing contributes to excessive use, unwanted side effects (e.g., allergic reactions, gastrointestinal symptoms, emergency department visits),6 and antibiotic resistance.7 Antibiotic resistance is a global public health threat and its reduction is a priority.8 Initiatives such as Choosing Wisely aim to reduce antibiotic overuse and advise against using antibiotics for URTIs that are viral in origin.7 However, while the risks of inappropriate and overuse are established, antibiotic prescribing is challenging and providers must balance the pressure of diagnostic uncertainty, time constraints, and patient expectations and preferences against the undesirable consequences of overprescribing.8 Thus, there is interest in management approaches that aid decision-making and reduce excessive prescribing and use. Various interventions are available that address inappropriate antibiotic prescribing and the pressures of providing in-person care for patients with URTIs. These include delayed (post-dated) antibiotic prescriptions9 and different interventions to guide the use of antibiotics (e.g., clinical decision support tools, rapid point-of-care testing [POCT], viral prescription pads). 10 The desired outcome is to reduce the overprescribing of antibiotics and antibiotic resistance, and potentially to improve clinical outcomes (e.g., reduce harms from antibiotics) and reduce health care utilization such as hospital and emergency department visits. Changes to health care service delivery and organization due to the COVID-19 pandemic mean providers in primary care face difficulty in caring for patients with URTIs.7 Practical guidance and interventions continue to be required to assist clinicians in making care decisions for patients with upper respiratory tract symptoms. Resources such as the Using Antibiotics Wisely campaign's updated The Cold Standard toolkit provide resources for clinicians to support virtual and in-person management.11 However, there continues to be an interest and need for evaluating contemporary evidence to identify which interventions might be most effective for supporting shared decision-making and optimizing the care of people with URTIs. This report aims to summarize the evidence regarding the clinical effectiveness of delayed antibiotic prescription-filling interventions and other family medicine interventions to influence the use of antibiotics for suspected acute URTIs.