TABLE 1

Description of included studies

Study author and referenceStudy descriptionNo. and age of participantsFactor(s) examinedaAuthors' conclusions and summary of key findingsb
Ahmed et al. (20)Retrospective cross-sectional study of pediatric patients presenting to primary care providers' offices, convenient care clinics, and emergency departments for upper RTI, pharyngitis, or bronchitis904 children aged 0–18 yrdx, sp, age, sex, ins, st, fv, cmb, co, cngEmergency department physicians and family practice physicians were more likely to prescribe antibiotics for acute respiratory illnesses than pediatricians
Akkerman et al. (29)Prospective cross-sectional study of factors associated with antibiotic prescribing for acute otitis media458 patients aged 0–87 yr with a median age of 4 yrage, sv, pppePatients who should not have been prescribed an antibiotic according to guidelines were younger than 24 mo and more severely ill according to GP, and their GP assumed their parents expected an antibiotic
Akkerman et al. (35)Prospective cross-sectional study of patients with sinusitis, tonsillitis, or bronchitis assessing patients' expectations of antibiotics for their illness and factors affecting inappropriate prescribing1,490 patients aged 0–98 yrins, co, sv, pppe, inflam, whz, agePatients who received an antibiotic prescription that was not in accordance with the Dutch national guidelines had more inflammation signs, such as fever, were more severely ill according to their GP, and their GP more frequently assumed that they expected an antibiotic than those who did not receive an antibiotic prescription
Altiner et al. (42)Prospective cross-sectional study of patients presenting with acute cough, examining factors associated with antibiotic prescription2,745 patients aged 16–96 yrsv, fv, sm, dos, age, n pt fv, sv pt prThe more severely ill a patient was rated by their physician, the more likely they were to receive antibiotics, especially if the rest of the patients in that physician's practice were relatively healthy
Aspinall et al. (21)Prospective cross-sectional study of patients presenting with acute respiratory illness to Veterans Affairs emergency departments667 patients with a mean age of 55 yrcmb, fv, spm, sob, abs, dx, age, spAntibiotic use was high and varied substantially for URIs and acute bronchitis; specific signs and symptoms, a diagnosis of acute bronchitis, and provider age and specialty were associated with antibiotic prescribing
Brown et al. (30)Retrospective cross-sectional database review to assess factors related to antibiotic prescription for acute upper respiratory tract infections2,413 patients aged 18–64 yrdx, age, sex, race, urb63% of people received antibiotics for a nonbacterial respiratory tract infection
Butler et al. (36)Data obtained from a prospective cohort of primary care networks from 13 European countries, looking at antibiotic prescription for acute cough as well as patient symptom resolution over time2,419 patients aged 35–60 yrspmAdults presenting in primary care with an acute cough and who produced discolored sputum were more likely to be prescribed antibiotics
Cadieux et al. (34)Retrospective cross-sectional data obtained from a historical cohort and administrative databases, assessing factors associated with inappropriate antibiotic prescriptions for acute respiratory illness104,230 patient encounters over 9 yrmcq, img, yr in p, volPhysicians who had been in practice longer, who were international medical graduates, and who had high-vol practices were more likely to prescribe antibiotics inappropriately
Cadieux et al. (37)Retrospective cross-sectional data from historical cohort and administrative database assessing physician clinical skills on licensing exams in relation to inappropriate antibiotic prescribing129,592 patient encounters over 15 yrloc, dx, sex, age, urb, pt edu, pt inc, cmb, p clin sc, vol, img, spBetter clinical and communication skills on licensing exams reduced the risk of antibiotic prescription for viral respiratory infections among female physicians but not male physicians; younger, more well-educated patients were less likely to be prescribed an antibiotic; patients with more comorbidities were more likely to receive antibiotics
Coenen et al. (22)Prospective cross-sectional data collection to assess factors affecting antibiotic prescription for acute cough1,448 patients presenting to GP office with acute coughage, cmb, sm, sv, pppe, dos, spm, fv, ha, mya, whz, sob, cp, ano, fat, hr, abs, pd, re, fu, gpt, fee, geo, spiro, p age, p load, hm vPhysician-perceived patient demand for antibiotics is associated with prescription of antibiotics
Coenen et al. (44)Cross-sectional data from a prospective cohort from 13 European countries assessing the association of patient expectations with physician prescribing practices2,690 patients with a median age of 48 yrpt exp, pt hp, pt ask, pppePatient expectations, hopes, or asking for antibiotics were not associated with symptom severity at presentation or symptom resolution during the subsequent 28 days regardless of whether an antibiotic was prescribed; patient expectations and physician perception of patient views were strongly associated with antibiotic prescribing
Dosh et al. (45)Cross-sectional study of factors associated with prescription of antibiotics for acute respiratory infections in outpatient family practice482 patients over the age of 4 yrrhin, pnd, pur ND, abs, sin tnPresence of rales, rhonchi, sinus tenderness, postnasal drainage, purulent nasal discharge, and clinician's perceptions of clinical course of the illness affected the likelihood of antibiotic prescription
Fischer et al. (23)Prospective cross-sectional study using medical student observation to assess factors associated with antibiotic prescription for respiratory tract infections273 patients aged 14–88 yrab ph, tm abn, la, abs, sin tn, fat, whz, fv, spmAntibiotic prescribing was associated with specific patient symptoms and physical exam results
Gaur et al. (38)Retrospective cross-sectional examination of NHAMCS data to determine factors associated with antibiotic prescription for viral respiratory tract infections1,952 patients aged 0–18 yrage, sex, race, geo, ins, dx, hous st, nontch, bf glStaff physicians are more likely to prescribe antibiotics for viral respiratory tract illness than trainees, and staff at non-teaching hospitals are more likely to prescribe antibiotics than staff at teaching hospitals
Gonzales et al. (11)Retrospective cross-sectional database review to assess factors related to antibiotic prescription for acute upper respiratory tract infections548 patients aged greater than 18 yr oldage, sex, race, geo, ins, spOnly rural practice was an independent risk for antibiotic therapy for URIs
Gonzales et al. (24)Retrospective cross-sectional data from an insurance database was used to assess factors associated with antibiotic prescription in acute upper respiratory tract infection322 patients above the age of 18 yrsm, pur ND, spm, ab ph, tm abn, sin tn, la, fv, cmb, mis wk33% of patients with URI were prescribed antibiotics, often in the setting of purulent manifestations, with purulent nasal discharge, green phlegm production, tonsillar exudate, and current tobacco use predicting antibiotic prescription for URIs
Holmes et al. (25)Cross-sectional survey of physicians assessing factors associated with antibiotic prescribing for acute respiratory illness391 patients above the age of 16 yrsex, age, spm, absAlthough the minority of patients had abnormal signs on physical exam, when present, discolored sputum and abnormal chest findings increased the chances of antibiotic prescription
Kozyrskyj et al. (43)Retrospective cross-sectional study of population-based database to assess factors associated with antibiotic prescription4,870 patients with a mean age of 85 yrp age, img, sp, year, sea, age, sex, pt incAlmost half of physician visits for viral RTIs resulted in an antibiotic prescription, and second-line antibiotics were prescribed in 20% of visits for common childhood infections
Ladd (33)Study utilizing retrospective cross-sectional data from NHAMCS and NAMCS databases to assess the prescribing practices of nurse practitioners compared to physicians and the factors that influence antibiotic prescribing in each group14,198 patient encounters over a 5-yr periodloc, dx, year, sex, age, geo, race, ins, sup medNPs have prescribing practices for viral upper respiratory tract infection similar to those of MDs; patient race and insurance type influenced NP antibiotic prescribing
Linder and Singer (47)Prospective survey at the time of patient encounter to assess influence of patient desire for antibiotics on physician prescribing practices310 patients with a mean age of 34 yrpt exp, abs, ab ph39% of patients wanted antibiotics; wanting antibiotics was associated with antibiotic prescription
Linder and Stafford (39)Retrospective cross-sectional study using NAMCS database to examine antibiotic prescriptions for sore throat1,852 patients above the age of 18 yr with a mean age of 38 yryear, age, sex, race, ins, sp, geo, urbPredictors of antibiotic use for sore throat were younger patient age and physician specialty being general practice
Mangione-Smith et al. (26)Prospective nested cohort study of factors associated with inappropriate antimicrobial prescribing and parental satisfaction with the visit306 parents of pediatric patientsrace, pt inc, prev abx, otal, st, co, cmb, rhin, tm abn, pt exp, pppe, p attPhysicians were significantly more likely to inappropriately prescribe antibiotics if they believed a parent desired antimicrobials
Moro et al. (27)Prospective cross-sectional survey of patients presenting to pediatricians with respiratory tract infections4,352 patient encountersage, imi, day care, pppe, ab ph, sin tn, otal, periorb, diar, tm abn, la, otor, fv, rhin, cmb, p ageNo difference in the probability of antibiotic prescription was found between ambulatory practices and hospital emergency service pediatricians; the presence of an interviewer in the ambulatory practice was negatively associated with antibiotic prescription
Nyquist et al. (28)Retrospective cross-sectional data from NAMCS database was used to look at factors affecting prescribing for children with acute respiratory illness531 patients aged 0–18 yrage, sex, race, geo, urb, ins, spColds, URIs, and bronchitis accounted for over 20% of all antibiotic prescriptions provided by U.S. ambulatory physicians to children (<18 years) in 1992
Roumie et al. (31)Retrospective cross-sectional study using NAMCS and NHAMCS data to assess factors associated with antibiotic prescription patterns1,504 patients presenting to outpatient or emergency department with acute respiratory illnessloc, sp, hous stOdds of receiving an antibiotic were greater in a visit to a non-physician clinician for respiratory diagnosis where antibiotics are rarely indicated; resident physicians prescribe fewer antibiotics for respiratory diagnoses where antibiotics are rarely indicated than physicians or non-physician clinicians
Rutschmann and Domino (40)Retrospective cross-sectional review of NAMCS data to assess relationship between physician specialty and antibiotic prescribing for URI956 patients over the age of 18 yrage, sex, race, geo, urb, ins, sp, pcp, time, cxr, yearAntibiotics were still prescribed for more than 40% of the URIs seen in adult ambulatory practice between 1997 and 1999 in the U.S.
Smith et al. (46)Retrospective cross-sectional assessment of NAMCS and NHAMCS data to assess factors affecting antibiotic prescription for acute rhinosinusitis881 patients with a mean age of 46.2 yrsp, age, cmbFirst, antibiotics continue to be widely prescribed to treat ARS; second, when physicians prescribe antibiotics for ARS visits, they choose broad-spectrum antibiotics in the majority of cases; third, there are significant variations in antibiotic prescribing for ARS by physician specialties and patient age
Stanton et al. (41)Prospective survey assessing relationship between smoking status and antibiotic prescription for acute cough2,549 patients above the age of 18 yrage, cmb, sm, dosPrimary care clinicians prescribed antibiotics more frequently to smokers than nonsmokers; this suggests that, despite differences in training and practice setting, clinicians have similar attitudes toward prescribing antibiotics for smokers
  • a Abbreviations for patient-level factors: ab ph, abnormal pharynx; abs, altered breath sounds; age, patient age; ano, anorexia; chil, chills; cmb, patient comorbidity; cng, congestion; co, cough; cp, chest pain; cxr, chest X-ray performed; day care, child attendance at day care; diar, diarrhea; dos, duration of symptoms; dx, diagnosis; dx test, diagnostic tests ordered; fat, fatigue; fv, fever; gen, general symptoms; ha, headache; hr, high risk patient as determined by physician; htn, hypertension; hypox, hypoxia; imi, parents born abroad; inflam, signs of inflammation; ins, patient medical insurance type; la, lymphadenopathy; meds, other concurrent medications; mis wk, patient missed work; mya, myalgias; otor, otorhea/otalgia; pain, moderate to severe pain; p att, patient attitude toward antibiotic prescribing; p clin sc, physician clinical skills exam score; pd, percussion dullness; periorb, periorbital edema; pnd, postnasal discharge; ppc, perceived parental concern about child's illness; prev abx, previous antibiotics for similar illness; pt ask, patient asked physician for antibiotic; pt edu, patient level of education; pt exp, patient expectation for antibiotic; pt hp, patient hope for antibiotic; pt inc, patient income; pur ND, purulent nasal discharge; race, patient race; rhin, rhinorrhea; rr, elevated respiratory rate; se, patient concern about side effects of antibiotics; sex, patient sex; sin tn, sinus tenderness; sm, patient is a smoker; sob, shortness of breath; spm, sputum; st, sore throat; sup med, patient on supportive (nonantibiotic) medication; sv, severity of illness; tach, tachycardia; time, time spent with patient; tm abn, tympanic membrane abnormality; viral, viral diagnosis noted by physician; wait, patient waited >2 h to see physician; whz, wheeze. Abbreviations for provider-level factors: bact, physician belief that acute bronchitis and URI caused by bacteria; br spc, tendency of physician to use broad-spectrum antibiotics; fee, fee structure and billing; fu, follow up with physician; gpt, general practitioner special training; high rx, physician high prescriber; hm v, mean number of physician home visits; hous st, housestaff compared to staff physicians; img, international medical graduate; loc, physician practice location; mcq, physician score on infectious diseases component of licensing exam; non phy, patient seen by provider other than medical doctor; nontch, physicians at non-teaching hospitals compared to staff at teaching hospitals; n pt fv, number of patients in the physician's practice with fever; own, physician owns medical practice; p age, physician age; ph sex, physician sex; phy blf, physician belief about antibiotics for treatment of colds; p load, physician patient load; pppe, physician perception of patient expectations; p/t, physician works part-time; re, patient referral; solo, physician in solo practice; sp, physician specialty; spiro, availability of spirometry in physician office; sv pt pr, severity of other patients' illnesses within physician's practice; vol, physician practice volume; vol URI, volume of URI diagnosis in physician practice; yr in p, physician years in practice. Abbreviations for environment-level factors: bf gl, prior to guideline update compared to after; geo, geographic location; new, new patient; pcp, physician is patient's primary care provider; sea, season; urb, urban vs rural; year, year of visit.

  • b GP, general practitioner; NP, nurse practitioner; MD, medical doctor; ARS, acute rhinosinusitis.