Reducing Expectations for Antibiotics in Patients With Upper Respiratory Tract Infections

A Primary Care Randomized Controlled Trial

Anna Ishani Perera, MBChB; Mark Greenslade Thomas, MD; Keith James Petrie, PhD; Janet Frater, MBChB; Daniel Dang, PhD; Kiralee Ruth Schache, MHP; Amelia Frances Akroyd, MHP; Stephen Robert Ritchie, PhD


Ann Fam Med. 2021;19(3):232-239. 

In This Article

Abstract and Introduction


Purpose: Many family practitioners prescribe antibiotics for patients with upper respiratory tract infections (URTIs) to meet patients' expectations. We evaluated the impact of providing brief tablet-based information about antibiotic treatment of URTIs on patients' expectations for antibiotics and on family practitioners' antibiotic-prescribing behavior.

Methods: We performed a 3-arm randomized controlled trial among patients presenting with URTIs at 2 urban family practices in Auckland, New Zealand, during winter 2018. Participants were randomly allocated to view a presentation about the futility of antibiotic treatment of URTIs, the adverse effects associated with antibiotics, or the benefits of healthy diet and exercise (active control), immediately before their consultation. Before and after viewing the presentations, participants used a Likert scale to rate the strength of their belief that antibiotics are effective for treating URTIs and of their desire to be prescribed an antibiotic. Patients reported whether an antibiotic had been prescribed, and pharmacy dispensing records were reviewed to determine whether an antibiotic was dispensed.

Results: Participants who viewed either the futility or the adverse effects presentation had greater reductions in their expectations to receive antibiotics than the control group. The mean reduction (95% CI) was 1.1 (0.8–1.3) for the futility group, 0.7 (0.4–0.9) for the adverse effects group, and 0.1 (0–0.3) for the control group (Cohen d = 0.7; P <.001). There was no significant difference among the 3 groups with regard to antibiotic prescribing (P = .84) or dispensing (P = .43).

Conclusions: A brief tablet-based waiting room intervention significantly reduced participants' expectations about receiving antibiotics for URTI immediately before their family practitioner consultation. The intervention did not influence family practitioner prescribing behavior, however.


Overuse of antibiotics drives the emergence and spread of antimicrobial-resistant organisms, which pose a major threat to public health.[1] Globally, 85% to 95% of human antibiotics consumed are prescribed in outpatient settings such as family practice clinics and urgent care facilities.[2] The majority of non–guideline adherent, or inappropriate, antibiotic prescribing at these sites is for patients with self-limiting upper respiratory tract infections (URTIs), for which antibiotics confer marginal clinical benefit.[3,4] When antibiotics provide little or no benefit, the risk of antibiotic-related harms far outweigh the potential benefits.[5,6] Curtailing inappropriate antibiotic prescribing for patients with URTI is necessary to reduce harm and to slow the development of antimicrobial-resistant organisms.

Numerous psychosocial factors influence prescribing of antibiotics for URTIs. One factor that significantly drives inappropriate antibiotic prescribing is patients' expectations. Cross-sectional research indicates that the majority of family practitioners would prescribe antibiotics for a URTI to satisfy patient expectations,[7] despite knowing that this treatment would be ineffective for the patient's illness.[8] Physicians were more likely to prescribe antibiotics for a hypothetical patient perceived to have high expectations for antibiotics than for a hypothetical patient with low expectations.[9] Many patients with URTIs expect to receive antibiotics,[10,11] and many patients underestimate the harms of antibiotics and wrongly believe that these medications are useful for treating URTIs.[10,12] Therefore, reducing patients' expectations for antibiotic treatment of URTIs could significantly reduce inappropriate antibiotic prescribing. There is little evidence, however, that educational interventions, delivered at the point of care, can significantly change patients' expectations of being prescribed an antibiotic.[13]

The Necessity-Concern Framework posits that patients' medication beliefs and behaviors are determined by the balance between the perceived necessity of a medication for maintaining health, and concern about the consequences of taking the medication.[14] Using this framework, we devised 2 tablet-based presentations designed to reduce patients' expectations for antibiotics of URTIs.

We conducted a trial in which patients presenting with symptoms of URTI were randomized to view 1 of 3 presentations focused on the futility of antibiotics for an URTI (designed to reduce "necessity" beliefs) or on the risk of antibiotic-related adverse effects (designed to increase "concern" beliefs) or on the benefits of a healthy lifestyle without information about antibiotics or URTI (active control). We measured the effect of the presentations on patients' beliefs that antibiotics are helpful for URTIs, their expectations of being prescribed an antibiotic, and their actual receipt of an antibiotic prescription.