Quality improvement Randomised controlled trial

Delayed prescribing for respiratory tract infections in primary care results in lower antibiotic use 10.1136/eb-2014-110012

Morten Lindbæk Department of General Practice, University of Oslo, Antibiotic Centre for Primary Care, Oslo, Norway Correspondence to: Morten Lindbæk, Department of General Practice, University of Oslo, Antibiotic Centre for Primary Care, PO Box 1130 Blindern, Oslo NO 0317, Norway; [email protected]

Commentary on: Little P, Moore M, Kelly J, et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ 2014;348:g1606.

Context Eighty to 90% of all antibiotics are prescribed in primary care, mostly by general practitioners (GPs). Around 60% of these are prescribed for acute respiratory tract infections (RTIs), prescriptions which in many cases are unnecessary as most RTIs are either self-limiting bacterial conditions or of viral origin. A clear relationship between total antibiotic prescribing and development of resistance has been demonstrated, both on an individual and a societal level.1 2 However, in primary care the diagnostic tools are limited, resulting in diagnostic uncertainty, and it is often not easy to single out the few patients who clearly are in need of antibiotic treatment. In cases of uncertainty, delayed prescription can be a valuable tool to avoid unnecessary antibiotic use, resulting in a shared decisionmaking with the patient. Previous randomised trials have demonstrated that only 30–50% of the antibiotics prescribed are dispensed and used by the patient. However, one review has concluded that the effect of a delayed prescribing strategy is doubtful, and that a non-prescribing strategy results in a lower prescription for RTIs.3

Results Three hundred and thirty-seven (37%) patients were prescribed immediate antibiotics and 556 (63%) entered the randomised trial. There were no significant differences in symptom severity on days 2–4 between the groups, including the immediate prescription group. Furthermore, no significant differences were found in symptom duration between the groups with no prescription and a delayed prescription (median 3 vs 4 days). In the non-prescription group, 26% ended up with a prescription, while in the delayed prescription group, antibiotics were dispensed between 33% and 39% of patients. There were no significant differences between the groups with regard to satisfaction with the consultation, while the immediate prescription group had a significantly stronger belief in antibiotics. Median time for dispensing of antibiotics was 4 days in all the groups of delayed prescribing.

Commentary This is by far the largest study on delayed prescriptions for RTIs in primary care. It confirms previous findings that delayed prescribing is a safe strategy and that less than half of the patients receiving such a prescription actually have the medication dispensed. Furthermore, it demonstrates that there were no significant differences in patient outcomes or antibiotics dispensed between the various forms of delayed prescription. However, there are some limitations regarding external validity. First, there are large differences within and between countries regarding whether GPs use delayed prescription for RTIs in their daily practice. In southern Europe delayed prescription is hardly used, and in Norway a large study demonstrated that 11% of all prescriptions for RTIs were delayed.4 In the present study 86% of the patients were offered an antibiotic prescription and around 60% of them ended up with taking an antibiotic course. This is a higher rate of antibiotic consumption than in the Scandinavian countries (which have a rate of 30–40%) and is presumably also higher than in ordinary GP practice in the UK.5 The study’s conclusion is in conflict with Spurling and colleagues’ review, which concludes that no prescription is better than delayed prescription for keeping a low antibiotic rate for RTIs.3 However, the study is an important contribution in the field of delayed prescribing for RTIs in general practice. Competing interests None.


Methods The present study was a randomised multicentre trial conducted in UK primary care, including 889 patients with acute RTIs aged 3 years and above. Patients assessed as not needing immediate antibiotics were randomised to four strategies of delayed prescription, which involved either recontact for a prescription, postdated prescription, collection of the prescription or being given the prescription. In addition, a no antibioticprescribing strategy was added. The main outcome measures were: mean symptom severity at days 2–4, antibiotic use and patients’ belief in antibiotic use. Secondary outcomes were: time to symptom resolution, side effects and complications. The study was non-blinded and the follow-up period was 2 weeks.

1. Goossens H, Ferech M, Vander Stichele R, et al. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005;365:579–87. 2. Costelloe C, Metcalfe C, Lovering A, et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096. 3. Spurling G, Del Mar C, Dooley L, et al. Delayed antibiotics for symptoms and complications of respiratory infections. Cochrane Database Syst Rev 2010;3: CD004417. 4. Høye S, Gjelstad S, Lindbæk M. Effects on antibiotic dispensing rates of interventions to promote delayed prescribing for respiratory tract infections in primary care. Br J Gen Pract 2013;63:e777–86. 5. Butler C, Hood K, Verheij T, et al. Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. BMJ 2009;338:b2242.

Evid Based Med October 2014 | volume 19 | number 5 |


Delayed prescribing for respiratory tract infections in primary care results in lower antibiotic use.

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