John: Hello, I'm John Hilton, editor in the Cochrane Editorial and Methods department. As the number of Cochrane and other systematic reviews increases, we are seeing a rising need for overviews that bring together the findings from multiple reviews. In September 2017, the Cochrane Acute Respiratory Infections Group did this for eight systematic reviews of ways to influence prescribing behaviour. Chris Del Mar, from the Cochrane group, tells us more in this podcast.

Chris: Hello, I’m Chris Del Mar from the Acute Respiratory Infections group.
Today I’m talking about an overview of systematic reviews called 'Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care'. This was led by Sarah Tonkin-Crine.
The background to this is that this overview addresses the antibiotic resistance global crisis. We want to try and assist primary care clinicians reduce the amount of antibiotics they prescribe for acute respiratory infections. This is a narrative overview and we synthesised evidence from systematic reviews rather than individual trials. We searched seven databases using Cochrane standard methods, assessing methodological quality using the ROBIS tool, and GRADE to assess the quality of evidence in the included studies.
We looked at eight systematic reviews of which five were Cochrane Reviews. Only three reviews scored low risk of bias overall, the remaining five scoring high risk, and so of course the Randomised Controlled Trials included in the review similarly varied in both size and risk of bias. One set of interventions looked at Point-of-Care tests: there were two looked at, C-reactive protein (CRP) and that was effective at reducing antibiotic prescribing, so also was procalcitonin-guided management – more in primary care than it was in emergency care. Shared decision-making also significantly reduced prescribing of antibiotics. The evidence for clinician educational materials and decision support was mixed and of lower quality, and we were unable to draw conclusions about their effects. We carefully looked for potential adverse effects of these interventions focussed on the consequences of not using antibiotics so commonly – so, extra hospital admissions or death – as well as extra return visits. We also looked to see if there were any patient satisfaction of course. The evidence for this was poor and we didn’t find enough evidence to be sure although we didn’t find any evidence of such harm. We looked for but didn’t find any evidence of changes in costs following the interventions.
So our conclusions are that there are interventions that are effective in reducing clinician prescribing of antibiotics for acute respiratory infections in primary care but there isn’t quite enough research on using several interventions simultaneously which we hope would be at least additive and perhaps multiplicative. We actually need more high-quality trials to further investigate these investigations.

John: If you’d like to read the overview and watch for updates of it and the including reviews should those news trials become available, just go to Cochrane Library dot com and search ‘antibiotic prescribing behaviour’.