Credit CDC Get Smart Campaign
# 8363
With the specter of increased antibiotic resistance increasing daily, doctors and researchers are looking for ways to improve the stewardship – and hopefully the useful life – of our dwindling arsenal of antibiotics. As we saw last week in CDC: Improving Antibiotic Prescribing Practices In Hospitals, reductions in antibiotic prescribing can also reduce a patient’s risk of developing a Clostridium difficile infection as well.
Despite these known (and serious) downsides to overprescribing antibiotics, patients have come to expect an antibiotic whenever they have a respiratory `infection’, even when the cause is likely to be viral instead of bacterial.
And many doctors – rather than having a patient return in a few days if they get `worse’ – will go ahead and prescribe an antibiotic . . . just in case. It’s not an unreasonable concern, particularly considering how difficult it can be for a patient to get into to see a busy doctor again on short notice, and the possibility that some small percentage of conservatively treated patients could experience complications without antibiotics.
We’ve research study today from the BMJ (pub. March 6th), that looks at varying strategies to reduce or delay the dispensing of antibiotics for acute respiratory infections, and their relative outcomes. As the authors write:
Delayed prescription is recommended in international guidance, and the National Institute for Health and Care Excellence currently recommends using a strategy of either no antibiotic prescriptions or a delayed antibiotic prescription for dealing with uncomplicated acute sore throats and other respiratory infections.
Assessing nearly 900 patients (aged 3 years and older) presenting with respiratory tract infections, clinicians across 25 practices in the UK deemed 37% were ill enough to require immediate antibiotics, while 63% were assigned to different delayed Rx strategy cohorts.
The primary finding — patient-reported symptom severity on days 2 to 4 — did not differ significantly between the five groups, including those who were prescribed antibiotics initially.
Just as interestingly, of those who fell into the delayed Rx categories - but had an option to request or fill an Rx later if they felt their symptoms were worsening - fewer than 40% ended up taking antibiotics. Indicating that a little patient education, along with handing out a script, can go a long way towards reducing antibiotic consumption.
Research
Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g1606 (Published 6 March 2014)
Cite this as: BMJ 2014;348:g1606
Paul Little, National Institute for Health Research senior investigator and professor of primary care research, Michael Moore, reader in primary care research, Jo Kelly, trial manager, Ian Williamson, senior lecturer in primary care research, Geraldine Leydon, reader in health research, Lisa McDermott, research fellow, Mark Mullee, director of the National Institute for Health Research research design service South Central, Beth Stuart, research fellow On behalf of the PIPS Investigators
Abstract
Objective To estimate the effectiveness of different strategies involving delayed antibiotic prescription for acute respiratory tract infections.
Design Open, pragmatic, parallel group, factorial, randomised controlled trial.
Setting Primary care in the United Kingdom.
Patients 889 patients aged 3 years and over with acute respiratory tract infection, recruited between 3 March 2010 and 28 March 2012 by 53 health professionals in 25 practices.
Interventions Patients judged not to need immediate antibiotics were randomised to undergo four strategies of delayed prescription: recontact for a prescription, post-dated prescription, collection of the prescription, and be given the prescription (patient led). During the trial, a strategy of no antibiotic prescription was added as another randomised comparison. Analysis was intention to treat.
Main outcome measures Mean symptom severity (0-6 scale) at days 2-4 (primary outcome), antibiotic use, and patients’ beliefs in the effectiveness of antibiotic use. Secondary analysis included comparison with immediate use of antibiotics.
Results Mean symptom severity had minimal differences between the strategies involving no prescription and delayed prescription (recontact, post-date, collection, patient led; 1.62, 1.60, 1.82, 1.68, 1.75, respectively; likelihood ratio test χ2 2.61, P=0.625). Duration of symptoms rated moderately bad or worse also did not differ between no prescription and delayed prescription strategies combined (median 3 days v 4 days; 4.29, P=0.368). There were modest and non-significant differences in patients very satisfied with the consultation between the randomised groups (79%, 74%, 80%, 88%, 89%, respectively; likelihood ratio test χ2 2.38, P=0.667), belief in antibiotics (71%, 74%, 73%, 72%, 66%; 1.62, P=0.805), or antibiotic use (26%, 37%, 37%, 33%, 39%; 4.96, P=0.292). By contrast, most patients given immediate antibiotics used antibiotics (97%) and strongly believed in them (93%), but with no benefit for symptom severity (score 1.76) or duration (median 4 days).
Conclusion Strategies of no prescription or delayed antibiotic prescription result in fewer than 40% of patients using antibiotics, and are associated with less strong beliefs in antibiotics, and similar symptomatic outcomes to immediate prescription. If clear advice is given to patients, there is probably little to choose between the different strategies of delayed prescription.
What is already known on this topic
Strategies involving no antibiotic prescription or delayed antibiotic prescription are common in managing respiratory tract infections
But systematic reviews have suggested that delayed prescription could result in worse symptom control than immediate use of antibiotics, and could lead to higher antibiotic use than a no prescription strategy
Different methods of delaying prescriptions (such as giving prescriptions with instructions, leaving prescriptions for collection, post-dating prescriptions, or requesting recontact) have been used but not directly compared
What this study adds
There is probably little difference in symptom control in the short term between strategies of delayed prescription, no prescription, or immediate prescription, despite strong belief in the effectiveness of antibiotics among patients
Both no and delayed antibiotic prescription result in the minority of patients using antibiotics
With clear guidance, any strategy of delayed prescribing is likely to result in fewer than 40% of patients using antibiotics
For more on antibiotic stewardship strategies, you may wish to revisit:
CDC Telebriefing (March 4th): Improving Antibiotic Prescribing Practices
AAP/CDC: New Guidance On For Antibiotics For Children
Study: Risks & Benefits Of Antibiotics For Acute Respiratory Infections
