Generating matrix of evidence

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A unique feature of Epistemonikos is that it connects systematic reviews and their included studies. This allows clustering systematic reviews based on the primary studies they have in common. The concept of 'systematic reviews sharing included studies' is a proxy of 'systematic reviews answering a similar question'.

A matrix of evidence is a tabular way of displaying the cluster of systematic reviews that share included studies, and all the studies included in these reviews. It is automatically created based on the connections of the database, and can be trimmed by the user in order to reflect an accurate body of evidence for a specific question.

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The matrix that will be created from this review contains Systematic reviews / Primary studies. loading

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The matrix of evidence is created based on the primary studies that systematic reviews have in common. For this reason it is not possible to generate a matrix of evidence from an empty review (i.e. a review that did not include any study)

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17 Primary studies Studify 100%Randomized controlled trial (RCT)
Little P2001Le Saux N2005Spiro DM2006Hoberman A2011Mygind N1981Appelman CL1991Tähtinen PA2011Howie VM1972Laxdal OE1970Halsted C1968McCormick DP2005Burke P1991van Buchem FL1981Thalin, A1985Kaleida PH1991Damoiseaux RA2000Neumark T2007
5 Systematic reviews
Damoiseaux RA1998Del Mar C1997Gisselsson-Sole..2014Rovers MM2006Vouloumanou EK2009
10 References ( articles) loading Revert Studify

Primary study

Unclassified

Evaluation of phenoxymethylpenicillin treatment of acute otitis media in children aged 2-16.

blocked
Journal Scandinavian journal of primary health care
Year 2007
Links Pubmed DOI PubMed Central
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OBJECTIVE: To study the clinical recovery from acute otitis media (AOM) in children, 2-16 years of age, managed with or without treatment with phenoxymethylpenicillin (PcV). DESIGN: An open, prospective randomized trial. Children aged between 2 and 16 years, presenting with one- or double-sided AOM (without perforation) with symptom duration of less than four days, were included. The children were randomized to PcV for five days or to no primary antibiotic treatment. A health score and compliance were registered on a daily basis for seven days. SETTING: A total of 32 health centres and 72 GPs in south-east Sweden. Subjects. Children aged 2-16 presenting with earache. MAIN OUTCOME MEASURES: Recovery time, symptom duration, frequency of complications (up to three months) and consumption of healthcare services independent of treatment with or without antibiotics. RESULTS: A total of 179 patients carried out the trial; 92 were randomized to PcV, 87 to no primary antibiotic treatment. The median recovery time was four days in both groups. Patients who received PcV had less pain (p <0.001) and used fewer analgesics. There were no significant differences in the number of middle-ear effusions or perforations at the final control after three months. Children randomized to PcV treatment consulted less (p <0.001) during the first seven days. CONCLUSIONS: Our investigation supports that PcV treatment of AOM does not affect the recovery time or complication rates. PcV provided some symptomatic benefit in the treatment of AOM in otherwise healthy children, aged 2-16 years.

Primary study

Unclassified

Randomised study of myringotomy, amoxycillin/clavulanate, or both for acute otitis media in infants.

Journal Lancet
Year 1989
Links Pubmed DOI
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In a prospective study, 105 infants aged 3-12 months with acute otitis media were randomly assigned to one of three treatment groups: amoxycillin/clavulanate ('Augmentin') alone (36 patients), myringotomy plus placebo (35 patients), or augmentin plus myringotomy (34 patients). The last two groups were double-blinded. Bacterial pathogens, mainly Haemophilus influenzae (of which 20% were beta-lactamase producers) and Streptococcus pneumoniae, were isolated from 60% of the ear exudates and all isolates were sensitive to augmentin. Most of the infants improved clinically within 3-6 days irrespective of the treatment protocol. As judged by otoscopy, 60% of the patients receiving augmentin, with or without myringotomy, recovered completely compared with 23% of patients treated with myringotomy plus placebo. Treatment with augmentin was also more effective than myringotomy with regard to persistence of ear infection. In the myringotomy plus augmentin group closure of the incision and resolution of the discharge from the incision site was faster than in the myringotomy plus placebo group. The addition of myringotomy to augmentin did not seem to affect either the persistence of the infection after treatment or the residual middle ear effusion.

Primary study

Unclassified

Randomised study of myringotomy, amoxycillin/clavulanate, or both for acute otitis media in infants.

Journal Lancet
Year 1989
Links Pubmed DOI
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In a prospective study, 105 infants aged 3-12 months with acute otitis media were randomly assigned to one of three treatment groups: amoxycillin/clavulanate ('Augmentin') alone (36 patients), myringotomy plus placebo (35 patients), or augmentin plus myringotomy (34 patients). The last two groups were double-blinded. Bacterial pathogens, mainly Haemophilus influenzae (of which 20% were beta-lactamase producers) and Streptococcus pneumoniae, were isolated from 60% of the ear exudates and all isolates were sensitive to augmentin. Most of the infants improved clinically within 3-6 days irrespective of the treatment protocol. As judged by otoscopy, 60% of the patients receiving augmentin, with or without myringotomy, recovered completely compared with 23% of patients treated with myringotomy plus placebo. Treatment with augmentin was also more effective than myringotomy with regard to persistence of ear infection. In the myringotomy plus augmentin group closure of the incision and resolution of the discharge from the incision site was faster than in the myringotomy plus placebo group. The addition of myringotomy to augmentin did not seem to affect either the persistence of the infection after treatment or the residual middle ear effusion.

Primary study

Unclassified

Randomised study of myringotomy, amoxycillin/clavulanate, or both for acute otitis media in infants.

Journal Lancet
Year 1989
Links Pubmed DOI
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In a prospective study, 105 infants aged 3-12 months with acute otitis media were randomly assigned to one of three treatment groups: amoxycillin/clavulanate ('Augmentin') alone (36 patients), myringotomy plus placebo (35 patients), or augmentin plus myringotomy (34 patients). The last two groups were double-blinded. Bacterial pathogens, mainly Haemophilus influenzae (of which 20% were beta-lactamase producers) and Streptococcus pneumoniae, were isolated from 60% of the ear exudates and all isolates were sensitive to augmentin. Most of the infants improved clinically within 3-6 days irrespective of the treatment protocol. As judged by otoscopy, 60% of the patients receiving augmentin, with or without myringotomy, recovered completely compared with 23% of patients treated with myringotomy plus placebo. Treatment with augmentin was also more effective than myringotomy with regard to persistence of ear infection. In the myringotomy plus augmentin group closure of the incision and resolution of the discharge from the incision site was faster than in the myringotomy plus placebo group. The addition of myringotomy to augmentin did not seem to affect either the persistence of the infection after treatment or the residual middle ear effusion.

Primary study

Unclassified

Penicillin and acute otitis: short and long-term results.

Journal The Annals of otology, rhinology & laryngology. Supplement
Year 1981
Links Pubmed DOI
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The effect of peroral penicillin V (55 mg/kg/day) on acute otitis media was investigated in 149 children between the ages of one and ten years in a double-blind, placebo-controlled investigation. The parameters of the disease employed were symptom scores for earache, the use of analgetics, otoscopy, as well as tympanometry. The children were followed up for three months. Penicillin had a significant effect on pain on the second day of treatment. The acute course of the disease was satisfactory in 69% of the children in the placebo group and in 86% in the penicillin group. In patients with pneumococci or hemolytic streptococci in the rhinopharynx, the pain already disappeared after one to two doses of penicillin, whereas the treatment had no effect on the patients with Haemophilus influenzae. There was no difference between the penicillin and placebo groups with regard to the results of otoscopy and tympanometry after one week, one month and three months. No serious complications were observed. It is concluded that an attitude of "masterful inactivity" with regard to the treatment of acute otitis media is justifiable, and in the majority of cases advisable, provided sufficient analgesic treatment is given and also that the patient can be closely followed. As there are still many unanswered questions more controlled investigations are warranted.

Systematic review

Unclassified

Interventions to improve antibiotic prescribing practices in ambulatory care

blocked
Journal Cochrane database of systematic reviews (Online)
Year 2005
Links Pubmed DOI PubMed Central RxForChange www.epistemonikos.org
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BACKGROUND: The development of resistance to antibiotics by many important human pathogens has been linked to exposure to antibiotics over time. The misuse of antibiotics for viral infections (for which they are of no value) and the excessive use of broad spectrum antibiotics in place of narrower spectrum antibiotics have been well-documented throughout the world. Many studies have helped to elucidate the reasons physicians use antibiotics inappropriately. OBJECTIVES: To systematically review the literature to estimate the effectiveness of professional interventions, alone or in combination, in improving the selection, dose and treatment duration of antibiotics prescribed by healthcare providers in the outpatient setting; and to evaluate the impact of these interventions on reducing the incidence of antimicrobial resistant pathogens. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialized register for studies relating to antibiotic prescribing and ambulatory care. Additional studies were obtained from the bibliographies of retrieved articles, the Scientific Citation Index and personal files. SELECTION CRITERIA: We included all randomised and quasi-randomised controlled trials (RCT and QRCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies of healthcare consumers or healthcare professionals who provide primary care in the outpatient setting. Interventions included any professional intervention, as defined by EPOC, or a patient-based intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed study quality. MAIN RESULTS: Thirty-nine studies examined the effect of printed educational materials for physicians, audit and feedback, educational meetings, educational outreach visits, financial and healthcare system changes, physician reminders, patient-based interventions and multi-faceted interventions. These interventions addressed the overuse of antibiotics for viral infections, the choice of antibiotic for bacterial infections such as streptococcal pharyngitis and urinary tract infection, and the duration of use of antibiotics for conditions such as acute otitis media. Use of printed educational materials or audit and feedback alone resulted in no or only small changes in prescribing. The exception was a study documenting a sustained reduction in macrolide use in Finland following the publication of a warning against their use for group A streptococcal infections. Interactive educational meetings appeared to be more effective than didactic lectures. Educational outreach visits and physician reminders produced mixed results. Patient-based interventions, particularly the use of delayed prescriptions for infections for which antibiotics were not immediately indicated effectively reduced antibiotic use by patients and did not result in excess morbidity. Multi-faceted interventions combining physician, patient and public education in a variety of venues and formats were the most successful in reducing antibiotic prescribing for inappropriate indications. Only one of four studies demonstrated a sustained reduction in the incidence of antibiotic-resistant bacteria associated with the intervention. AUTHORS' CONCLUSIONS: The effectiveness of an intervention on antibiotic prescribing depends to a large degree on the particular prescribing behaviour and the barriers to change in the particular community. No single intervention can be recommended for all behaviours in any setting. Multi-faceted interventions where educational interventions occur on many levels may be successfully applied to communities after addressing local barriers to change. These were the only interventions with effect sizes of sufficient magnitude to potentially reduce the incidence of antibiotic-resistant bacteria. Future research should focus on which elements of these interventions are the most effective. In addition, patient-based interventions and physician reminders show promise and innovative methods such as these deserve further study.

Systematic review

Unclassified

Do delayed prescriptions reduce antibiotic use in respiratory tract infections? A systematic review.

Authors Arroll B , Kenealy T , Kerse N
Journal The British journal of general practice : the journal of the Royal College of General Practitioners
Year 2003
Links Pubmed PubMed Central RxForChange
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BACKGROUND: There is concern about the increasing resistance of antibiotics to common bacteria. Delayed prescribing for respiratory tract infections is a strategy that may reduce the use of antibiotics. AIM: To systematically review controlled trials of delayed prescriptions to establish their capacity to reduce antibiotic intake. DESIGN OF STUDY: A systematic review of the literature. SETTING: Four studies were conducted in the United Kingdom and one in New Zealand. METHODS: We searched MEDLINE from 1966 to April 2003, EMBASE, and the Cochrane Controlled Trials Register using the following terms: 'delayed', 'antibiotics', 'prescriptions', and 'back-up' (as in back-up prescription). We included controlled trials of studies in which the intervention was a delayed prescription compared to an immediate prescription for patients with upper respiratory tract infections. The studies were selected independently and the results compared. Disagreements were resolved by discussion. The data and quality of the studies were extracted and assessed independently by two of the authors. RESULTS: Four randomised controlled trials and one before-after controlled trial contributed to the review. The relative risk in the randomised trials for lower antibiotic usage when a delayed prescription was given ranged from 0.54 for the common cold to 0.25 for otitis media. CONCLUSION: The consistent reduction in antibiotic usage in the five controlled trials included in this review suggests that delayed prescription is an effective means of reducing antibiotic usage for acute respiratory infections. The duration of delay for prescriptions ranged widely, from 1 to 7 days.

Systematic review

Unclassified

Duration of symptoms of respiratory tract infections in children: systematic review.

Journal BMJ (Clinical research ed.)
Year 2013
Links Pubmed DOI PubMed Central
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OBJECTIVE: To determine the expected duration of symptoms of common respiratory tract infections in children in primary and emergency care. DESIGN: Systematic review of existing literature to determine durations of symptoms of earache, sore throat, cough (including acute cough, bronchiolitis, and croup), and common cold in children. DATA SOURCES: PubMed, DARE, and CINAHL (all to July 2012). ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials or observational studies of children with acute respiratory tract infections in primary care or emergency settings in high income countries who received either a control treatment or a placebo or over-the-counter treatment. Study quality was assessed with the Cochrane risk of bias framework for randomised controlled trials, and the critical appraisal skills programme framework for observational studies. MAIN OUTCOME MEASURES: Individual study data and, when possible, pooled daily mean proportions and 95% confidence intervals for symptom duration. Symptom duration (in days) at which each symptom had resolved in 50% and 90% of children. RESULTS: Of 22,182 identified references, 23 trials and 25 observational studies met inclusion criteria. Study populations varied in age and duration of symptoms before study onset. In 90% of children, earache was resolved by seven to eight days, sore throat between two and seven days, croup by two days, bronchiolitis by 21 days, acute cough by 25 days, common cold by 15 days, and non-specific respiratory tract infections symptoms by 16 days. CONCLUSIONS: The durations of earache and common colds are considerably longer than current guidance given to parents in the United Kingdom and the United States; for other symptoms such as sore throat, acute cough, bronchiolitis, and croup the current guidance is consistent with our findings. Updating current guidelines with new evidence will help support parents and clinicians in evidence based decision making for children with respiratory tract infections.

Systematic review

Unclassified

Predictors of pain and/or fever at 3 to 7 days for children with acute otitis media not treated initially with antibiotics: a meta-analysis of individual patient data.

Journal Pediatrics
Year 2007
Links Pubmed DOI
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OBJECTIVE: The goal was to determine the predictors of a prolonged course for children with acute otitis media. METHODS: A meta-analysis of data with the observation groups of 6 randomized, controlled trials was performed. Participants were 824 children, 6 months to 12 years of age, with acute otitis media. The primary outcome was a prolonged course of acute otitis media, which was defined as fever and/or pain at 3 to 7 days. RESULTS: Of the 824 included children, 303 had pain and/or fever at 3 to 7 days. Independent predictors of a prolonged course were age of < 2 years and bilateral acute otitis media. The absolute risk of pain and/or fever at 3 to 7 days for children < 2 years of age with bilateral acute otitis media (20% of all children) was 55%, and that for children > or = 2 years of age with unilateral acute otitis media (47% of all children) was 25%. CONCLUSIONS: The risk of a prolonged course was 2 times higher for children < 2 years of age with bilateral acute otitis media than for children > or = 2 years of age with unilateral acute otitis media. Clinicians can use these features (ie, age of < 2 years and bilateral acute otitis media) to inform parents more explicitly about the expected course of their child's otitis media and to explain which features should prompt parents to contact their clinician for reexamination of the child.

Systematic review

Unclassified

Interventions to Reduce Unnecessary Antibiotic Prescribing: A Systematic Review and Quantitative Analysis

blocked
Journal Medical care
Year 2008
Links Pubmed DOI RxForChange
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BACKGROUND: Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We performed a systematic review and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing for acute outpatient illnesses for which antibiotics are often inappropriately prescribed. RESEARCH DESIGN AND METHODS: We searched the Cochrane Collaboration?s Effective Practice and Organisation of Care database, supplemented by MEDLINE and manual review of article bibliographies. We included randomized trials, controlled before-after studies, and interrupted time series. Two independent reviewers abstracted all data, and disagreements were resolved by consensus and discussion with a third reviewer. The primary outcome was the absolute reduction in the proportion of patients receiving antibiotics. RESULTS: Forty-three studies reporting 55 separate trials met inclusion criteria. Most studies (N = 38) addressed prescribing for acute respiratory infections (ARIs). Among the 30 trials eligible for quantitative analysis, the median reduction in the proportion of subjects receiving antibiotics was 9.7% [interquartile range (IQR), 6.6-13.7%] over 6 months median follow-up. No single QI strategy or combination of strategies was clearly superior. However, active clinician education strategies trended toward greater effectiveness than passive strategies (P = 0.096). Compared with studies targeting specific conditions or patient populations, broad-based interventions extrapolated to larger community-level impacts on total antibiotic use, with savings of 17-117 prescriptions per 1000 person-years. Study methodologic quality was fair. CONCLUSIONS: QI efforts are effective at reducing antibiotic use in ambulatory settings, although much room for improvement remains. Strategies using active clinician education and targeting management of all ARIs (rather than single conditions in single age groups) may yield larger reductions in community-level antibiotic use. Copyright © 2008 by Lippincott Williams & Wilkins.
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