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Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working and modify as needed.

Require Explicit Written Justification for Non-recommended Antibiotic Prescribing
Reference Interventions and Outcomes Methods, Participants, and Settings Intervention Conclusions
Chao JH, et al. Comparison of two approaches to observation therapy for acute otitis media in the emergency department. Pediatrics. 2008. 121(5):e1352–6. Intervention

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


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

Parental visit satisfaction


Prospective randomized trial


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


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


232 patients enrolled, 206 patients completed follow-up

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 therapy was well accepted by parents of children with AOM.

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


de la Poza A, et al. Prescription strategies in acute uncomplicated respiratory infections: A randomized clinical trial. JAMA Intern Med 2016. 176(1):21–9. Interventions:

4 antibiotic prescriptions strategies for acute uncomplicated respiratory tract infections.

  • Delayed antibiotic prescription given to patients at the visit with instructions to wait to fill it unless not improving
  • Delayed antibiotic prescription awaiting patient at clinic, patient to return and collect prescriptions if not improving
  • Immediate antibiotic prescription issued at visit
  • No antibiotic prescription issued at visit


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


Adults with acute, uncomplicated respiratory infections


23 primary care clinics in Spain


405 adult patients with acute, uncomplicated respiratory infections

Delayed prescription strategies led to lower antibiotic use:

  • 91% of patients used antibiotics in the immediate prescription group;
  • 33% of patients used antibiotics in the group with delayed prescription;
  • 23% of patients used antibiotics in the group who had to collect the delayed prescription;
  • 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.

Delayed prescription strategies for acute uncomplicated respiratory tract infections are effective in decreasing antibiotic use.
Francis NA, et al. Delayed antibiotic prescribing and associated antibiotic consumption in adults with acute cough. Br J Gen Pract 2012. 62(602):e639–46. Intervention

No intervention; observational study


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


General practitioners

Adult patients with acute cough


14 primary care networks in 13 European countries


3368 patients with acute cough

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.

Delayed antibiotic prescribing was not used often for adults presenting to primary care.

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

Little P, et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA 2005. 22;293(24):3029–35.



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


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


37 English general practitioners

Patients aged ≥3 years with acute uncomplicated lower respiratory infections


Primary care clinics in England


807 patients recruited

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.


Not prescribing antibiotics, or offering a delayed antibiotic prescribing is associated with minimal differences in symptom burden and may reduce antibiotic use.


Little P, et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomized controlled trial.

Brit Med J 2014. 348:g1606.



Delayed antibiotic prescribing strategies

  • Re-contact for a prescription (i.e., patient calls for the prescription)
  • Post-dated prescription
  • Post-visit collection of a prescription

No antibiotic prescription


Primary: Symptom severity at days 2–4

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


Open, pragmatic, randomized controlled trial


Patients aged ≥3 years with acute respiratory tract infections


25 primary care clinics in the United Kingdom


889 patients recruited

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 antibiotic prescriptions or no prescription strategies resulted in fewer than 40% of prescribed antibiotics being used among patients.

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


McCormick DP, et al. Nonsevere acute otitis media: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment. Pediatrics 2005.115(6):1455–65.



Watchful waiting (WW) versus immediate antibiotic prescription

Educational intervention


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)


Children aged 6 months to 12 years with nonsevere AOM


Pediatric clinics in in the United States (Texas)


223 children recruited

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.

Immediate antibiotic treatment was associated with decreased treatment failures and improved symptom resolution compared with WW, but also higher adverse drug events and higher likelihood of carriage of multi-drug resistant S. pneumoniae.

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.


Siegel R, et al. Treatment of otitis media with observation and a safety-net antibiotic prescription. Pediatrics 2003. 112(3):527–31.



Delayed antibiotic prescription (“safety-net prescription”)


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


Children aged 1 to 12 years with nonsevere AOM


11 pediatric clinics in the United States


194 children enrolled, 175 with complete follow-up

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.


Safety-net prescriptions can decrease antibiotic use for non-severe AOM, and some parents find it an acceptable treatment strategy.


Spiro DM, et al. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. 2006. 296(10):1235–41.



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


Filling of the antibiotic prescription

Clinical symptoms and symptoms resolution



Randomized controlled trial


Children aged 6 months to 12 years with AOM


Emergency department in Northeastern United States


283 children

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.

Wait and see antibiotic prescriptions reduced antibiotic use in children with AOM.
Communication Skills Training
Reference Methods, Participants, and Settings Intervention Conclusions
Little P, et al. Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomized, factorial, controlled trial. Lancet. 2013. 382(9899):1175–82. Intervention

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


Changes in antibiotic prescribing for respiratory tract infections (RTIs)


Cluster randomized controlled trial


Primary care providers


246 primary care clinics in 6 European countries

4264 patients

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.


Internet training for CRP testing and communications skills led to reductions in antibiotic prescribing for RTIs.
Cals JW, et al. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial. Annals of Family Medicine. 2013. 11(2):157–64.



Physician enhanced communication skills training

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


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


Patients with family physician visits for RTIs


20 family practices in the Netherlands

379 patients

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.


Communications training led to sustained reductions in the percent of RTIs leading to antibiotic prescriptions, while CRP testing did not.
Require Explicit Written Justification for Non-recommended Antibiotic Prescribing
Reference Interventions and Outcomes Methods, Participants, and Settings Results Conclusions
Meeker et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: A randomized clinical trial. JAMA 2016. 315(6):562–70. Interventions: 3 behavioral interventions

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


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


Cluster randomized clinical trial


248 primary care clinicians


47 primary care practices in the United States

31,712 visits for acute respiratory tract infections for which antibiotics are not indicated

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.

Accountable justification and peer comparison interventions reduced antibiotic prescribing for acute respiratory tract infections for which antibiotics are not indicated
Clinical Decision Support
Reference Interventions and Outcomes Methods, Participants, and Settings Results Conclusions
McGinn TG, et al. Efficacy of an evidence-based clinical decision support in primary care practices: A randomized clinical trial. JAMA Intern Med 2013. 173(17):1584–11. Intervention

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


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

Use of clinical prediction rule in EHR


Randomized clinical trial


Attending physicians, fellows, residents and nurse practitioners

Patients with complaints consistent with pharyngitis or pneumonia


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

168 primary care providers with 984 visits with clinical decision rule triggered

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 prediction rules integrated into EHRs can reduce inappropriate antibiotic prescribing.
Jenkins TC, et al. Effects of clinical pathways for common outpatient infections on antibiotic prescribing. Am J Med. 2013;126(4):327–35 e312. Intervention

Clinical decision support targeting antibiotic prescribing for common conditions

Patient education materials


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


Clinicians working in primary care clinics


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

8 primary care clinics

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 was associated with reduced antibiotic prescriptions for non-pneumonia ARIs and reduced use of broad-spectrum antibiotics during one year of implementation.
Gonzales R, et al. A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis. JAMA Intern Med 2013. 173(4):267–73. Interventions

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


Reductions in antibiotic prescribing for acute uncomplicated bronchitis.


Cluster randomized controlled trial


Primary care clinicians


33 primary care practices in the United States (Pennsylvania)

12,776 visits for acute bronchitis

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.

Clinical decision support strategies for acute bronchitis can help reduce overuse of antibiotics in primary care.

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

Rattinger GB, et al. A sustainable strategy to prevent misuse of antibiotics for acute respiratory infections. PLoS One 2012. 7(12):e51147. Intervention

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


Guideline concordance and proportion of inappropriate antibiotic prescribing

Reductions in fluoroquinolone and azithromycin use



Non-randomized retrospective controlled study


Primary care providers for an outpatient veteran population


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


3831 patients

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).


A clinical decision support system decreased unwarranted use of fluoroquinolones and azithromycin for ARI and improved antibiotic use for ARI in an outpatient veterans’ healthcare system.
Linder JA, et al. Documentation-based clinical decision support to improve antibiotic prescribing for acute respiratory infections in primary care: A cluster randomized controlled trial. Inform Prim Care 2009. 17(4):231–40. Intervention

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


Antibiotic prescribing for acute respiratory tract infections


Randomized controlled trial


Primary care providers


27 primary care clinics in the United States (Massachusetts)

21,961 visits for ARIs

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.

A clinical decision support tool for ARIs, the ARI Smart Form, was rarely used by clinicians and thus did not improve antibiotic prescribing for ARIs.
Forrest, C. B., et al. Improving adherence to otitis media guidelines with clinical decision support and physician feedback. Pediatrics 2013. 131(4): e1071–1081.



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

Audit and feedback to clinicians with peer comparison


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


Factorial-design cluster randomized trial


Primary care providers


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

24 practices with 139,305 visits for AOM and OME

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.

Both CDS and audit and feedback effectively increased adherence to guidelines for treatment of AOM and OME

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

Call Centers, Nurse Hotlines, or Pharmacist Consultations
Reference Interventions and Outcomes Methods, Participants, and Settings Results Conclusions
Harper R, et al. Optimizing the use of telephone nursing advice for upper respiratory infection symptoms. Am J Manag Care 2015. 21(4): 264–270. Intervention

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


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


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


Large healthcare system in the United States (California)

279,625 calls

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.

URI symptoms can be effectively managed by nurses via a telephone advice line.


  1. Soumerai SB, Avorn J. Principles of educational outreach (‘academic detailing’) to improve clinical decision making. JAMA. 1990;263(4):549-56.

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