Delayed Prescriptions Can Reduce Antibiotic Overuse

Nicola M. Parry, DVM

December 22, 2015

For adults with uncomplicated respiratory tract infections, delayed prescription strategies are associated with reduced antibiotic use compared with immediate prescriptions, according to the results of a randomized clinical trial published online December 21 in JAMA Internal Medicine.

"We found that the delayed strategy groups had slightly greater symptom burden and duration than the immediate prescription group, although the differences were not clinically relevant," write Mariam de la Poza Abad, MD, from the Doctor Carles Ribas Primary Care Center, Barcelona, Spain, and colleagues.

"Delayed prescription and no prescription strategies notably reduced antibiotic use compared with the immediate prescription group."

Respiratory tract infections are among the most common conditions that are managed in primary care. These infections are typically self-limiting, and recent studies have shown that antibiotics have little clinical effect on uncomplicated cases. Nevertheless, in the United States, about 60% of patients with a sore throat and 71% of those with acute uncomplicated bronchitis still receive an antibiotic prescription. Antibiotic overprescription not only promotes antibiotic resistance but also increases the likelihood of patients revisiting physicians for similar complaints.

Delayed antibiotic prescription is a strategy that involves advising patients to take the prescription only if disease symptoms either worsen or fail to improve a few days after the clinician consultation. Although this approach has the potential to reduce antibiotic use, studies have reported conflicting results about its effect on clinical outcomes in uncomplicated respiratory infections, and no data are available for the United States. Dr de la Poza Abad and colleagues therefore aimed to investigate the efficacy and safety of two delayed-prescription strategies in this patient population.

The researchers performed a multicenter, open-label, randomized clinical trial that included 398 adults with acute, uncomplicated respiratory infections. Patients were randomly assigned to one of four strategies: a delayed, patient-led strategy in which patients received an antibiotic prescription but were told to use it only if symptoms worsened or failed to improve within several days, a delayed collection strategy that required patients to collect their prescription from the primary care center 3 days postconsultation, an immediate prescription strategy, or a no prescription strategy.

The most common infections were pharyngitis (46.2%) and acute bronchitis (32.2%), and the presence of symptoms at the time of first consultation was similar in all four groups. The mean duration of severe symptoms was 5.1 days, 4.0 days, 3.6 days, and 4.7 days for patients in the delayed patient-led, delayed collection, immediate prescription, and no prescription groups, respectively (P = .002). The median duration of the maximum severity of any symptom was 5 days in all four groups (P = .009).

Among patients in the immediate prescription group, 91.1% used antibiotics; in the delayed patient-led, delayed collection, and no prescription groups rates of antibiotic use were significantly lower (P < .001), at 32.6%, 23.0%, and 12.1%, respectively. No differences in complications, adverse effects, or the need for unscheduled care were demonstrated among the four groups, and patients' general health statuses did not differ at 30 days postconsultation.

Absenteeism rates were significantly lower (P = .05) in the delayed patient-led (25.8%) and delayed collection (21.4%) groups than in the immediate prescription (33.3%) and no prescription (39.8%) groups. And although severe symptoms lasted from 0.4 days to 1.5 days longer in the delayed patient-led, delayed collection, and no prescription groups than in the immediate prescription group, patient satisfaction was high and similar among all four groups (P = .14).

Moreover, compared with the immediate prescription group (85.7%), significantly fewer patients (P = .06) in the delayed patient-led (69.0%), delayed collection (69.1%), and no prescription (70.2%) groups reported they would revisit their physician for the same illness. Overall, compared with the immediate prescription group (8.2%), more patients (P = .02) in the delayed patient-led (19.0%), delayed collection (15.6%), and no prescription (19.7%) groups believed that antibiotics were ineffective for acute respiratory infection.

"Delayed prescription strategies are a useful approach to management in patients with acute uncomplicated respiratory infections," the authors write. "When patients or physicians are concerned about the risk of complications, or when patients expect to be prescribed antibiotics, a delayed antibiotic strategy may be particularly helpful compared with a no prescription strategy."

They conclude, "In case of uncertainty, delayed strategies should become standard practice as they reduce antibiotic use and patient belief in antibiotic effectiveness."

In an invited commentary, Amanda R. McCullough, PhD, and Paul P. Glasziou, PhD, both from Bond University, Gold Coast, Australia, emphasize that the authors of this study have conducted the largest pragmatic trial of delayed antibiotic prescribing outside of Northern Europe. "Their findings corroborate the existing literature and are generalizable to those with acute respiratory infections in primary care," they write.

However, they note that delayed prescribing is not a perfect solution, but represents a compromise between an immediate prescription and a no prescription strategy. As such, even though some patients will still receive unnecessary antibiotics using a delayed prescription strategy, the evidence suggests these strategies do significantly reduce antibiotic overuse and therefore should be embraced.

"The challenge remains for researchers to define exactly what is involved in delayed prescribing, and how clinicians can use it in different practice contexts," they conclude.

The Instituto de Salud Carlos III, Spanish Ministry of Health, provided funding for this study. One coauthor received funding from the Jordi Gol i Gurina Foundation, the European Commission, the Catalan Society of Family Medicine, and the Instituto de Salud Carlos III. Another coauthor is funded by a Miguel Servet research contract from the Instituto de Salud Carlos III. The remaining authors and commentators have disclosed no relevant financial relationships.

JAMA Intern Med. Published online December 21, 2015. Article full text, Commentary full text

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