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


Our study shows that providing brief information to patients about either the futility of antibiotic treatment or the potential adverse effects of antibiotics, when they present to their family practitioner with an URTI, halves the patients' expectations for antibiotics. Although the study was not primarily designed to examine antibiotic prescribing, there was no corresponding decrease in this outcome despite the large reduction in participants' expectations for antibiotics. Participants who had strongly expected an antibiotic prescription were more likely to be prescribed an antibiotic, and to have an antibiotic dispensed in the week after their consultation. The receipt of antibiotic-related information before the consultation did not detrimentally affect patients' experience of their family practitioner visit. Taken together, our findings show that information about antibiotics was well received and understood by patients at a time when they were unwell and seeking care, but that providing them with this information did not influence their physicians' prescribing behavior.

Strengths and Limitations

Our findings are novel in providing causal evidence that patients' beliefs and expectations about antibiotics can be modified by provision of information in the family practice waiting room using a brief, low-cost intervention. Second, recruitment of a large sample was conducted at 2 family practices staffed by a total of 18 family practitioners. There was high retention of participants with full data obtained for 90% of the cohort. Participants were blinded to the aims of the study, and all study personnel were blinded to group allocation. Finally, to increase the validity of outcome data, we used 2 methods to measure family practitioners' prescribing behavior.

The study also had several limitations. Participants were recruited at only 2 family practices, both situated in wealthy, urban areas, serving populations who almost universally have good English proficiency. The study practices had low rates of antibiotic prescribing (30% overall) compared with other practices in New Zealand.[16] This difference may limit the generalizability of the intervention effects to other family practices in this country and elsewhere. Our intervention will need implementation testing in a larger number of practices over a prolonged period.

Comparison With Existing Literature

Our results are in agreement with those of other studies that highlight the impact of patients' beliefs and expectations on inappropriate antibiotic prescribing.[13] The reduction in patients' expectations that an antibiotic would be prescribed, seen in the intervention groups, can be explained by the Necessity-Concern Framework, which posits that patients' beliefs and behaviors relating to medication can be determined by the balance between the perceived necessity of a medication for maintaining health, and concern about the consequences of taking that medication.[14] Interestingly, provision of information about the futility of antibiotic treatment of URTIs (decreasing perception of necessity) had a similar effect on reducing patients' expectations for antibiotics as provision of information about adverse effects of antibiotics (raising awareness of concern). We did not focus our information on antimicrobial resistance as our previous research has shown that information about population-level antibiotic-related adverse effects was less effective than information about personal-level adverse effects,[16] which makes the information more salient to the individual.[17]

Although we reduced patients' expectations for an antibiotic prescription, doing so did not reduce antibiotic prescribing by family practitioners. This finding is surprising given that patients' expectations to receive antibiotics are stated to be the main driver of antibiotic prescribing for URTIs.[7,18] It is possible that participants tended to provide socially desirable responses on the questionnaires but made their real expectations clear in the consultation with the family practitioner. Regardless, we found that participants who strongly expected antibiotics were much more likely to receive an antibiotic prescription.

In general, prescribers overestimate patients' expectations for antibiotics.[8] This overestimation seems to be driven by the misconception that providing an antibiotic prescription is associated with higher patient satisfaction.[19] We found no differences between patients who were given an antibiotic prescription and those who were not in their reported level of satisfaction with their consultation.

Clearly, both patients' expectations and prescribers' perceptions of these expectations influence the decision about whether to prescribe an antibiotic. Future efforts to improve antibiotic prescribing need to involve both patients and their clinicians.

Implications for Research and Practice

This randomized controlled trial shows that patients' expectations for antibiotics can be modified in the family practice waiting room. The results also highlight that the success of any antimicrobial stewardship intervention in reducing prescribing is contingent on prescriber involvement, and they provide support for implementation of this patient education intervention in combination with a complementary prescriber-focused intervention.