Development of an intervention to reduce antibiotic use for childhood coughs in UK primary care using critical synthesis of multi-method research.BACKGROUND
 Overuse of antibiotics contributes to the global threat of antimicrobial resistance.  Antibiotic stewardship interventions address this threat by reducing the use of antibiotics in occasions or doses unlikely to be effective.  We aimed to develop an evidence-based, theory-informed, intervention to reduce antibiotic prescriptions in primary care for childhood respiratory tract infections (RTI).  This paper describes our methods for doing so.


 Green and Krueter's Precede/Proceed logic model was used as a framework to integrate findings from a programme of research including 5 systematic reviews, 3 qualitative studies, and 1 cohort study.  The model was populated using a strength of evidence approach, and developed with input from stakeholders including clinicians and parents.


 The synthesis produced a series of evidence-based statements summarizing the quantitative and qualitative evidence for intervention elements most likely to result in changes in clinician behaviour.  Current evidence suggests that interventions which reduce clinical uncertainty, reduce clinician/parent miscommunication, elicit parent concerns, make clear delayed or no-antibiotic recommendations, and provide clinicians with alternate treatment actions have the best chance of success.  We designed a web-based within-consultation intervention to reduce clinician uncertainty and pressure to prescribe, designed to be used when children with RTI present to a prescribing clinician in primary care.


 CONCLUSIONS
 We provide a worked example of methods for the development of future complex interventions in primary care, where multiple factors act on multiple actors within a complex system.  Our synthesis provided intervention guidance, recommendations for practice, and highlighted evidence gaps, but questions remain about how best to implement these recommendations.  The funding structure which enabled a single team of researchers to work on a multi-method programme of related studies (NIHR Programme Grant scheme) was key in our success.


 The feasibility study accompanying this intervention was prospectively registered with the ISRCTN registry ( ISRCTN23547970 ), on 27 June 2014.
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