The United Nations General Assembly described antibiotic resistance as the most urgent global risk. Some bacterial strains, such as carbapenem-resistant klebsiella pneumoniae, have few treatment choices. Infections with this bacterium are associated with a 40%-70% mortality rate. Moreover, some bacteria are considered not only difficult to treat but untreatable with established antibiotics.
There are statements of antimicrobial resistance (AMR) for every approved antibiotic available. Fewer antibiotic choices are available not only because of increased resistance to known therapies but also because fewer antibiotics are being developed. Bacteria can achieve prompt resistance, decreasing profitable interest in the development of new antibiotics. For example, from 1983 to 1987, 16 new antibiotics were permitted by the U.S. Food and Drug Administration (FDA). However, only six new antibiotics were permitted from 2010 to 2016.
Healthcare providers usually choose among two different modalities – providing the patient with a prescription and a recommendation to fill out later or leaving the prescription in the clinic and asking the patient to pick it up if their state deteriorates. Either way, the patient has full power over the decisions affecting their health. Provider-patient relationship is the key variable in this question. Therefore, that can become the first line solution for physician and primary care providers because it reduces patients’ reliance on an antibiotic while maintaining their satisfaction.
Review of the Literature
The review meant to provide an update on the evidence on the effectiveness of the existing interventions in the reduction of antibiotic prescription in adults with URIs. Accordingly, this comprehensive review was a multistep process. Particularly, it involved the identification of the databases with the relevant data sources, assessment of the articles’ abstracts, and the tabulation of the results.
Literature Search Strategy
The search strategy was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Accordingly, a systematic review was performed searching in the databases EBSCO, MEDLINE, PubMed, and CINAHL. These databases served as valuable sources of data because they contain a large plethora of scholarly articles. Several key terms were used to carry out the search in the selected databases. These search terms were antibiotic, prescription, interventions, respiratory tract infections, acute respiratory infections, reduction, and methods. The search process also encompassed assessing the bibliographies of the selected trial studies, which was instrumental in collecting additional relevant information on the interventions.
The screening process entailed the identification of citations that potentially met the inclusion criteria though the search of the databases. This step was followed by scanning the citations and removing duplicates. After screening the titles and abstracts of the remaining articles, sources that did not meet the inclusion criteria and did not bear relevance to the topic were excluded. The final step was the assessment of the articles’ full text to determine the final articles for the literature review.
The list of terms that were identified was applied in conducting a trial search, which enabled narrowing down the number of search terms to include only those that resulted in the generation of the most relevant articles. It is essential to point out that the original search strategy was developed using the Medical Subject Headings (MeSH) terminology. The search process was undertaken across all the selected databases with the assistance from the librarian.
The references of the articles identified via the search were compiled using EndNote X7. Articles published prior to 2011 were removed from the study. Thus, a total of 1,973 articles were retrieved for further screening (See Figure 1), then a full revision of the titles and abstracts of the articles took place. Any abstracts that appeared to be questionable were discussed and the decisions on their selection or disregard were made based on the quality and the significance of the results. The articles were then identified and downloaded for the analysis of their full text. Overall, 386 scholarly articles were reviewed (See Figure 1). After the execution of the eligibility phase, five articles that were the most relevant to the topic were included in this review (See Figure 1).
The information extracted from the articles included references, study design, sample/setting, variables, instruments, interventions/comparisons, results, implications, and limitations. Extraction of the limitations mentioned in the articles was instrumental in measuring their quality. This step was critical given that the differences in the study design made it difficult to utilize a formal quality assessment tool for the articles. It was vital to cross-check the information derived from the article to ensure consistency and quality in the data extraction process.
Evidence-Based Practice: Verification of Chosen Option
All interventions were categorized into two major categories: delayed prescriptions, and patient/public information and education. Two studies compared different types of delayed prescription.- Patient education was provided through brochures, or videotapes., Included studies reported a broad spectrum of outcomes. The most common outcomes were the use of antibiotics, prescription of antibiotics, filling of prescriptions by patients, and satisfaction with the treatment. Some studies focused on general practitioner views on delayed antibiotics methods and their confidence using such method.,
Delayed Antibiotic Prescription and Provider’s Education
The delayed prescription was given to the patients at the time of the initial visit, and patients were given directions to fill the prescription after a given time. Post-dated prescription: the delayed prescription was given at the time of the visit; however, it was post-dated. Delayed collection: the delayed prescription was not provided to patients at the time of the visit, but rather was lodged at the practice’s reception or pharmacy, and patients were invited to collect or fill their prescription if their symptoms had not improved or worsened after a few days.,, Worrall et al. reported the filling of the prescriptions by patients.
Almost all studies with delayed prescription significantly reduced the use of antibiotics for URIs. Overall, the participants in the delayed prescription cluster were less likely than participants in the immediate prescription group to use antibiotics. 32% of individuals given delayed prescriptions fill it compared to 93% of those given immediate prescriptions, which shows huge reduction of antibiotic use according to Sargent et al. 
Moreover, most of the studies emphasized on multidimensional interventions. Thus, studies by Kotwani and Holloway and May et al. examined two or more forms of interventions to address the issue of antibiotics over prescription to patients suffering from URIs. A recommended approach was classic providers education through holding collaborating seminars. The intervention involved the distribution of printed materials on the problem of antibiotic over prescription to facilitate education of the healthcare professionals.
The major themes that were discussed in the education materials included the diagnosis and therapy for URIs.,, Another significant theme that was covered in the use of education material was increasing bacterial resistance because of the unnecessary prescription of antibiotics for URIs treatment.
Effective communication is another significant intervention strategy highlighted in the studies. The purpose of this intervention is to address the pressure that providers face when prescribing antibiotics to their patients. Thus, providers learn about the best way of communicating with patients concerning their expectations on prescribing antibiotics to adequately respond to the concerns voiced by the patients. This intervention was illustrated in a few studies, in which the physicians were trained in seminars on effective communication techniques in the course of prescribing antibiotics.,
Raft et al.  reported in his study less than 10% of the physicians used delayed prescriptions to children with symptoms of URI, However, 46% were convinced that delayed prescription could reduce antibiotic use. The physicians’ opinions on delayed antibiotic prescription were considerably associated with their number of years working in general practice. Physicians with fewer years of practice had a positive outlook for delayed antibiotic prescriptions.
Using the Internet to conduct training was part of the recommended interventions to improve diagnosis. Consideration was given to the feedback that the participants provided . Thus, understanding the challenges that providers faced in the course of making prescriptions for their patients was essential.
Secondary outcomes included patients’ satisfaction with the treatment, and patients’ views on the effectiveness of antibiotics for URTIs. In the Little et al.  study, there was no significant difference in satisfaction between different variants of delayed prescription. de la Poza et al.  reported no significant difference in satisfaction between delayed collection, and immediate prescription groups.
There is sufficient evidence that delayed prescribing reduces antibiotic use, and the model has been introduced to general practitioners and adopted by the CDC. However, a study found the practice is not consistently used, with many primary providers voicing concerns about its implementation. More studies to identify which behavior-change are needed to target the theoretical framework domains that influence the use of delayed prescribing by primary care practitioners.
Some literature conflicts have been found on the benefits of public education methods. One review reported no or small benefit from printed educational materials  whereas McDonagh et al., agreed that public educational campaigns are not effective in reducing antibiotic use.
All the review studies have been in general outpatients’ settings, however, some of them have added step to analyze any hospital admission following delayed antibiotic use.,, Some studies in the review reported antibiotic prescription as their outcome. However, not all patients used their prescriptions. On the other hand, the studies that reported antibiotic use instead of antibiotic prescription relied on patients’ self-reports which may present desirability bias.