Delayed Antibiotic Prescription Research Articles

Perceptions and attitudes regarding delayed antibiotic prescription for respiratory tract infections: a qualitative study

BackgroundAntibiotics are overprescribed for respiratory tract infections (RTIs). However, the decision to prescribe is often complex. Delayed antibiotic prescription (DAP), a strategy designed to promote more rational antibiotic use, is still not widely used. The aim of this study was to explore perceptions and attitudes in primary care professionals, regarding antibiotic use and different DAP strategies for uncomplicated RTIs.MethodsWe conducted a qualitative study, using an inductive thematic approach to generate themes, based on focus group discussions and semi-structured interviews with professionals, recruited from 6 primary care centres (Barcelona metropolitan area, Spain).Results26 professionals (25 family physicians and one nurse) were included in four focus group discussions and three semi-structured interviews. Participants commented that RTIs were a main reason for consultation, motivated often by patient anxiety and fear of possible complications, and this was associated with the patients’ poor health-related education. Acknowledging inappropriate antibiotic use in the health system, participants attributed this, mainly to defensive medicine strategies. DAP was used when in doubt about the aetiology, and considering factors related to patient-physician interactions. The main perceived advantage of DAP was that it could reduce the need for additional visits, while the main disadvantage was uncertainty regarding proper use by the patient.ConclusionsDAP was used by participants in cases of doubt, in specific situations, and for specific patient profiles. Weak points were detected in our primary care system and its users that affect the proper use of both antibiotics and DAP, namely, time pressure on professionals, poor patient health-related education, and the lack of a patient-physician relationship in some scenarios.

A trial-based cost-effectiveness analysis of antibiotic prescription strategies for non-complicated respiratory tract infections in children

BackgroundAntibiotic prescription for respiratory tract infections (RTIs) in children attending primary care centres is almost double that predicted according to bacterial prevalence. Delayed antibiotic prescription (DAP) is designed to deploy a more rational use of antibiotics. While studies have evaluated DAP efficacy and safety for children with RTIs, little research has been conducted on the economic implications.MethodsOur trial compared cost-effectiveness for DAP, immediate antibiotic prescription (IAP), and no antibiotic prescription (NAP) for children aged 2–14 years with acute uncomplicated RTIs attended to in 39 primary care centres in Spain. The main outcome was the incremental cost-effectiveness ratio (ICER), measured in euros per gained quality-adjusted life days (QALDs). Net monetary benefit (NMB) was also calculated as a tool for decision making. The analysis was performed from a societal perspective for a time horizon of 30 days, and included healthcare direct costs, non-healthcare direct and indirect costs, and the antimicrobial resistance (AMR) cost.ResultsDAP was the most cost-effective strategy, even when the cost of AMR was included. QALD values for the three strategies were very similar. IAP compared to DAP was more costly (109.68 vs 100.90 euros) and similarly effective (27.88 vs 27.94 QALDs). DAP compared to NAP was more costly (100.90 vs 97.48 euros) and more effective (27.94 vs. 27.82 QALDs). The ICER for DAP compared to NAP was 28.84 euros per QALD. The deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the ICER. The cost-effectiveness acceptability curve showed that DAP was the preferred option in approximately 81.75% of Monte Carlo iterations, assuming a willingness-to-pay value of 82.2 euros per gained QALD.ConclusionsWhen clinicians are in doubt about whether an antibiotic is needed for children with RTIs attending PC centres, those treated with the DAP strategy will have slightly better efficiency outcomes than those treated with IAP because its costs are lower than those of IAP. DAP is also the most cost-effective strategy over a time horizon of 30 days if AMR is considered, despite higher short-term costs than NAP. However, if in the long term the costs of AMR are larger than estimated, NAP could also be an alternative strategy.Trial registrationThis trial has been registered at www.clinicaltrials.gov (identifier NCT01800747; Date: 28/02/2013 (retrospectively registered).

Patient Perspectives on the Drivers and Deterrents of Antibiotic Treatment of Acute Rhinosinusitis: a Qualitative Study.

Antibiotics are prescribed in >80% of outpatient acute rhinosinusitis (ARS) visits, despite the low incidence of bacterial infection. Previous studies have shown patient expectations are the most robust predictor of antibiotics prescription in ARS. However, patient perceptions are not well known or understood. To understand patient perceptions regarding what drives or deters them from wanting, seeking, and taking antibiotic treatment of ARS. Iterative thematic analysis of semi-structured interviews. Nineteen adults diagnosed with ARS within the prior 60 days at the Northwestern Medicine General Internal Medicine clinic in Chicago, IL. Perceptions of patients with ARS. We interviewed 19 patients, identifying the following drivers of antibiotic use: (1) symptoms, especially discolored rhinorrhea, and seeking relief, (2) belief that antibiotics are a convenient and/or effective way to relieve/cure sinusitis, and (3) desire for tangible outcomes of a clinic visit. For deterrents, the following themes emerged: (1) concern about antibiotic resistance, (2) preference for other treatments or preference to avoid medications, and (3) desire to avoid a healthcare visit. Patients identified that a trustworthy physician's recommendation for antibiotics was a driver, and a recommendation against antibiotics was a deterrent to taking antibiotics; a delayed antibiotic prescription also served as a deterrent. Antibiotic side effects were viewed neutrally by most participants, though they were a deterrent to some. Patients have misconceptions about the indications and effectiveness of antibiotics for ARS. Intimate knowledge of key antibiotic drivers and deterrents, from the perspective of patients with ARS, can be leveraged to engage and increase patients' knowledge, and set appropriate expectations for antibiotics for ARS.

A Comprehensive Review on Amoxicilin and Clavulanic Acid as Potential Antibacterial Agent

Suspensions comprise finely divided medication particles (the suspensoid) spread uniformly in a vehicle with or without stabilisers and other ingredients. Conventional oral suspension is ready-to-use and does not require reconstitution. Dry syrup is more bioavailable than tablets and capsules because it dissolves in water outside the mouth and enters the GI tract. GIT absorbs suspension quickly: Amoxicillin and clavulanic acid have been used since the 1970s. Despite having the same half-life as amoxicillin, clavulanic acid is protein-bound and heat unstable. It causes gastrointestinal side effects, including Clostridium difficile infection, and restricts amoxicillin oral combination doses. Due to clavulanic acid's b-lactamase tendency, the first amoxicillineclavulanic acid ratio was 4:1; currently it's 2:1, 7:1, 14:1, and 16:1. Few ratio comparisons exist. Amoxicillineclavulanic acid is often used as empiric therapy for WHO's Priority Infectious Syndromes in adults and children, resulting in large consumption. Some of these syndromes may be handled with a delayed antibiotic prescription approach or amoxicillin alone.

Cross-sectional internet survey exploring women’s knowledge, attitudes and practice regarding urinary tract infection-related symptoms in the Netherlands

ObjectivesUrinary tract infections (UTIs) are the most prevalent cause for women to consult a general practitioner (GP) and are commonly treated with (broad-spectrum) empirical antibiotics, even though 50% of UTIs...

Delayed Antibiotic Prescription for Children With Respiratory Infections: A Randomized Trial.

To assess the effectiveness and safety of delayed antibiotic prescription (DAP) compared to immediate antibiotic prescription (IAP) and no antibiotic prescription (NAP) in children with uncomplicated respiratory infections. Randomized clinical trial comparing 3 antibiotic prescription strategies. The participants were children with acute uncomplicated respiratory infections attended to in 39 primary care centers. Children were randomly assigned into prescription arms as follows: (1) DAP, (2) IAP, or (3) NAP. Primary outcomes were symptom duration and severity. Secondary outcomes were antibiotic use, parental satisfaction, parental beliefs, additional primary care visits, and complications at 30 days. In total, 436 children were included in the analysis. The mean (SD) duration of severe symptoms was 10.1 (6.3) for IAP, 10.9 (8.5) for NAP, and 12.4 (8.4) for DAP (P = .539), although the differences were not statistically significant. The median (interquartile range) of the greatest severity for any symptom was similar for the 3 arms (median [interquartile range] score of 3 [2-4]; P = .619). Antibiotic use was significantly higher for IAP (n = 142 [96%]) compared to DAP (n = 37 [25.3%]) and NAP (n = 17 [12.0%]) (P < .001). Complications, additional visits to primary care, and satisfaction were similar for all strategies. Gastrointestinal adverse effects were higher for IAP. There was no statistically significant difference in symptom duration or severity in children with uncomplicated respiratory infections who received DAP compared to NAP or IAP strategies; however, DAP reduced antibiotic use and gastrointestinal adverse effects.

Antimicrobial resistance awareness and antibiotic prescribing behavior among healthcare workers in Nigeria: a national survey

BackgroundAntimicrobial resistance (AMR) is a global problem compromising the effective treatment of infectious diseases. The World Health Organization (WHO) is encouraging and promoting awareness creation among health workers as one of its strategies to reduce the rate of emergence and transmission of AMR. Available data on the prescribing behavior of healthcare workers (HCWs) in Nigeria remains incomplete. This study was designed to provide an up-to-date estimate of the knowledge, attitude and antibiotic prescribing behavior of HCWs in Nigeria.MethodsThis is a cross-sectional study. Self-administered questionnaires were distributed to healthcare workers selected from six states, one each from the 6 geopolitical zones in Nigeria. A multi-stage sampling technique was used to reflect the three tiers of healthcare: primary, secondary and tertiary levels. Quantitative data was summarized using descriptive statistics. All data analysis was done using the Statistical package for social sciences version 26.0.ResultsOf the 420 questionnaires distributed, 358 (85.2%) responded. The mean year of practice of the respondents was 9.32 ± 7.8 years. About a half (50.3%) agreed that their prescribing behavior could promote antimicrobial resistance. 49.2% had a good knowledge of AMR and physicians had significantly better knowledge than other HCWs (X2 = 69.59, P < 0.001). Several participants prescribed antibiotics for common viral infections such as sore throats (75.7%), measles (37.7%), common cold and flu (21.2%). Over 60.3% admitted prescribing antibiotics just to be on the safe side. In general, 70.9% of the respondents frequently or moderately use practice guidelines while 25.7% often apply the delayed antibiotic prescription (DAP) strategy to reduce antimicrobial prescription.ConclusionThis study reveals an overall moderate level of knowledge of AMR and attitude towards minimizing the emergence of antimicrobial resistance though this did not translate significantly to practice. Further efforts must be made in order to improve rational prescription of antimicrobials among HCWs in Nigeria.

Use of delayed antibiotic prescription in primary care: a cross-sectional study

BackgroundOne of several strategies developed to reduce inappropriate antibiotic use in situations where the indication is not clear is delayed antibiotic prescription (DAP), defined as an antibiotic prescription issued for the patient to take only in case of feeling worse or not feeling better several days after the visit. We conducted a survey to identify DAP use in Spanish primary care settings.MethodsWe surveyed 23 healthcare centers located in 4 autonomous regions where a randomized controlled trial (RCT) on DAP was underway. The primary variable was use of DAP. Categorical and quantitative variables were analyzed by means of the chi-squared test and non-parametric tests, respectively.ResultsThe survey was sent to 375 healthcare professionals, 215 of whom responded (57.3% response rate), with 46% of these respondents declaring that they had used DAP in routine practice before the RCT started (66.6% afterwards), mostly (91.5%) for respiratory tract infections (RTIs), followed by urinary infections (45.1%). Regarding DAP use for RTIs, the most frequent conditions were pharyngotonsillitis (88.7%), acute bronchitis (62.7%), mild chronic obstructive pulmonary disease exacerbations (59.9%), sinusitis (51.4%), and acute otitis media (45.1%). Most respondents considered that DAP reduced emergency visits (85.4%), scheduled visits (79%) and inappropriate antibiotic use (73.7%) and most also perceived patients to be generally satisfied with the DAP approach (75.6%). Having participated or not in the DAP RCT (74.1% versus 46.2%; p < 0.001), having previously used or not used DAP (86.8% versus 44.2%; p < 0.001), and being a physician versus being a nurse (81.8% versus 18.2%; p < 0.001) were factors that reflected significantly higher rates of DAP use.ConclusionsThe majority of primary healthcare professionals in Spain do not use DAP. Those who use DAP believe that it reduces primary care visits and inappropriate antibiotic use, while maintaining patient satisfaction. Given the limited use of DAP in our setting, and given that its use is mainly limited to RTIs, DAP has considerable potential in terms of its implementation in routine practice.

Impact of antibiotics for children presenting to general practice with cough on adverse outcomes: secondary analysis from a multicentre prospective cohort study.

BackgroundClinicians commonly prescribe antibiotics to prevent major adverse outcomes in children presenting in primary care with cough and respiratory symptoms, despite limited meaningful evidence of impact on these outcomes.AimTo estimate the effect of children’s antibiotic prescribing on adverse outcomes within 30 days of initial consultation.Design and settingSecondary analysis of 8320 children in a multicentre prospective cohort study, aged 3 months to <16 years, presenting in primary care across England with acute cough and other respiratory symptoms.MethodBaseline clinical characteristics and antibiotic prescribing data were collected, and generalised linear models were used to estimate the effect of antibiotic prescribing on adverse outcomes within 30 days (subsequent hospitalisations and reconsultation for deterioration), controlling for clustering and clinicians’ propensity to prescribe antibiotics.ResultsSixty-five (0.8%) children were hospitalised and 350 (4%) reconsulted for deterioration. Clinicians prescribed immediate and delayed antibiotics to 2313 (28%) and 771 (9%), respectively. Compared with no antibiotics, there was no clear evidence that antibiotics reduced hospitalisations (immediate antibiotic risk ratio [RR] 0.83, 95% confidence interval [CI] = 0.47 to 1.45; delayed RR 0.70, 95% CI = 0.26 to 1.90, overall P = 0.44). There was evidence that delayed (rather than immediate) antibiotics reduced reconsultations for deterioration (immediate RR 0.82, 95% CI = 0.65 to 1.07; delayed RR 0.55, 95% CI = 0.34 to 0.88, overall P = 0.024).ConclusionMost children presenting with acute cough and respiratory symptoms in primary care are not at risk of hospitalisation, and antibiotics may not reduce the risk. If an antibiotic is considered, a delayed antibiotic prescription may be preferable as it is likely to reduce reconsultation for deterioration.

An underutilised resource for Antimicrobial Stewardship: a 'snapshot' of the community pharmacists' role in delayed or 'wait and see' antibiotic prescribing.

Various strategies have been implemented in primary care to address the inappropriate use of antibiotics, with varying degrees of success. One such intervention is delayed or 'wait and see' prescribing, where the prescriber indicates to wait a few days before dispensing the antibiotic. The aim of this study was to explore community pharmacists' perceptions and practice experiences with delayed antibiotic prescribing. An online survey was advertised in two professional pharmacy organisations' e-newsletters for community and internship pharmacists in Queensland, Australia, from January to April 2016. We received 120 responses. 103 (86%) worked in a community pharmacy. Sixty per cent of the respondents would not dispense the delayed antibiotic prescription if a patient presented to the pharmacy within 24 h of seeing a doctor. Instead, they would advise the patient to wait and fill the prescription if they are not improving. The concept of delayed or a 'wait and see' antibiotic prescription was well received by the participating community pharmacists. These healthcare professionals are well placed to be effective stewards of antibiotics and can play an important role in collaboration with other healthcare professionals to optimise the quality use of antibiotics in primary care.

Delayed Antibiotic Prescribing Strategies--Time to Implement?

26. De la Poza AbadM, Mas Dalmau G, Moreno BakedanoM, et al; Delayed Antibiotic Prescription (DAP)Working Group. Rationale, design and organization of the delayed antibiotic prescription (DAP) trial: a randomized controlled trial of the efficacy and safety of delayed antibiotic prescribing strategies in the non-complicated acute respiratory tract infections in general practice. 2013. http: //www.biomedcentral.com/content/pdf/1471-229614-63.pdf.

Oral corticosteroid use for clinical and cost-effective symptom relief of sore throat: study protocol for a randomized controlled trial

BackgroundManagement of acute sore throat poses a significant burden on UK general practices, with almost 10% of registered patients attending their GP with sore throat every year. Nearly half of all patients presenting with acute sore throat are treated with antibiotics, despite their limited effect. In a recent systematic review we demonstrated that a single dose of steroids reduced the severity and time to resolution of sore throat. However, all of the trials included looked at the use of steroids alongside antibiotics and only one was in a primary care setting. This trial aims to assess the efficacy and cost-effectiveness of a single oral dose of corticosteroids on symptoms of sore throat in patients receiving either a delayed antibiotic prescription or no antibiotics at all in UK primary care.Methods/DesignA double-blind, two arm, randomized, placebo controlled trial in adults (≥18 years of age) presenting to primary care with acute sore throat (<seven days). Participants are recruited on the day of presentation to their GP practice. GPs or nurses assess eligibility, record baseline clinical features and obtain a throat swab for bacterial culture. Participants are being randomized to treatment arms at a ratio of 1:1. Treatment arms will be stratified according to whether patients are being given a delayed antibiotic prescription or no antibiotic prescription and by recruiting centre (Oxford, Bristol or Southampton). Outcome data is being collected at 24 and 48 hours via text message or telephone call, from days 0 to 7 using a patient symptom diary and at one month via a GP notes review.DiscussionThis will be the first randomized controlled trial of oral corticosteroids in adults presenting to primary care with sore throat in the UK, and the first to examine the clinical and cost-effectiveness of oral corticosteroids for the treatment of sore throat in the absence of antibiotics.Trial registrationThis trial is registered with Current Controlled Trials on 26 March 2013, registration number: ISRCTN17435450.Electronic supplementary materialThe online version of this article (doi:10.1186/1745-6215-15-365) contains supplementary material, which is available to authorized users.

Rationale, design and organization of the delayed antibiotic prescription (DAP) trial: a randomized controlled trial of the efficacy and safety of delayed antibiotic prescribing strategies in the non-complicated acute respiratory tract infections in general practice

BackgroundRespiratory tract infections are an important burden in primary care and it’s known that they are usually self-limited and that antibiotics only alter its course slightly. This together with the alarming increase of bacterial resistance due to increased use of antimicrobials calls for a need to consider strategies to reduce their use. One of these strategies is the delayed prescription of antibiotics.MethodsMulticentric, parallel, randomised controlled trial comparing four antibiotic prescribing strategies in acute non-complicated respiratory tract infections. We will include acute pharyngitis, rhinosinusitis, acute bronchitis and acute exacerbation of chronic bronchitis or chronic obstructive pulmonary disease (mild to moderate). The therapeutic strategies compared are: immediate antibiotic treatment, no antibiotic treatment, and two delayed antibiotic prescribing (DAP) strategies with structured advice to use a course of antibiotics in case of worsening of symptoms or not improving (prescription given to patient or prescription left at the reception of the primary care centre 3 days after the first medical visit).DiscussionDelayed antibiotic prescription has been widely used in Anglo-Saxon countries, however, in Southern Europe there has been little research about this topic. The DAP trial wil evaluate two different delayed strategies in Spain for the main respiratory infections in primary care.Trial registrationThis trial is registered with ClinicalTrials.gov, number http://NCT01363531.

The English antibiotic awareness campaigns: did they change the public's knowledge of and attitudes to antibiotic use?

To determine the effect of the 2008 English public antibiotic campaigns. English and Scottish (acting as controls) adults aged > or = 15 years were questioned face to face about their attitudes to and use of antibiotics, in January 2008 (1888) before and in January 2009 (1830) after the antibiotic campaigns. Among English respondents, there was a small increase in recollection of campaign posters (2009 23.7% versus 2008 19.2%; P = 0.03), but this increase was only 2.3% higher in England than in Scotland. We did not detect any improvement in either England or Scotland, or any differences between England and Scotland in the understanding of the lack of benefit of antibiotics for coughs and colds, and we found no improvement in antibiotic use. We detected a significant increase in respondents retaining leftover antibiotics. Over 20% reported discussing antibiotics with their general practitioner (GP) or nurse in the year to January 2009. The offer of a delayed antibiotic prescription was reported significantly more often by English respondents (19% versus 8% Scottish in 2009; P = 0.01), and English respondents were advised to use other remedies for coughs and colds significantly more often in the year to January 2009 (12.7% in 2009 versus 7.4% in 2008; P < 0.001). There is little evidence that the 2008 public antibiotic campaigns were effective. The use and visibility of future campaign materials needs auditing. A carefully planned approach that targets the public in GP waiting rooms and through clinicians in consultations may be a more effective way of improving prudent antibiotic use.

Delayed Prescribing—A Sensible Approach to the Management of Acute Otitis Media

BASED ON EXPERIENCE IN HOLLAND, 1 EVIDENCE FROM systematic reviews, and recent evidence in the United Kingdom, many northern European countries, including the United Kingdom, have developed guidelines to advise physicians to delay for a short time before prescribing antibiotics for children with acute otitis media (AOM). The Dutch developed a policy of no prescription for AOM unless the patient has significant otalgia, fever, or both 72 hours after seeing the physician, or if a prolonged otic discharge develops. One study showed that if this watchful-waiting approach is used, there are likely to be few cases of complications (only 1 case of mastoiditis occurred in a 5000-patient cohort, and this patient had waited nearly a week). Patients and their families should be given clear advice about returning to see their physician if signs of complications occur, ie, worsening systemic features such as fever or vomiting. The study by Spiro and colleagues in this issue of JAMA is a welcome addition to the literature, suggesting that a “waitand-see” approach in the management of AOM is effective in the emergency department setting. Children randomized to the wait-and-see approach used fewer antibiotics (38% compared with 87%), and there was no difference in subsequent fever, otalgia, or unscheduled visits for medical care. The study provides evidence that there is probably little to be gained in terms of symptom resolution by immediate prescription of antibiotics for most children. Compared with previous trials of delayed antibiotic prescribing, the effect sizes are smaller than a Canadian study and similar to a United Kingdom study that used similar exclusion criteria. Further evidence of the limited utility of providing immediate antibiotics comes from a Cochrane review that suggests more than 15 children have to be treated for 1 child to benefit. The study by Spiro at al demonstrates that the wait-andsee approach is acceptable to parents in the United States, a finding that could have a substantial influence on the traditionally high rate of prescribing antibiotics for AOM in the United States. It also demonstrates that a wait-and-see approach works in the emergency department setting, where patients have no ongoing relationship with a physician. That children in such a setting might have worse outcomes had been a concern. However, several notes of caution are required. Both this study and previous studies excluded children whom clinicians considered to be toxic, and thus it would be unwise to extrapolate these results to very sick children. Furthermore, most children with AOM present within 24 hours after symptom onset. It would be unwise to suggest a further delay of 72 hours if the child already has a high fever and severe otalgia for 72 hours or longer, so the delaying times should be adjusted for the length of prior severe otalgia and fever. Especially in an emergency department setting, it would be advisable for physicians to emphasize the importance of repeat assessment if symptoms do not improve following the delayed prescription. There are several potential advantages of delayed prescribing. First, delayed prescribing rationalizes antibiotic use. Evidence from a systematic review of delayed prescribing trials for a variety of respiratory infections supports findings from the current study that delayed prescribing is likely to reduce antibiotic use. The study by Spiro et al suggests that a waiting period of 48 hours is likely to result in 62% of patients not using antibiotics; advising a wait of 72 hours is likely to result in even fewer antibiotic prescriptions being used. When patients are asked to return to collect their delayed antibiotic prescription from the physician’s office, antibiotic use is likely to be little greater than using a policy of no initial offer of antibiotics. Second, delayed prescribing changes patient and family beliefs about antibiotics. Prescribing antibiotics probably fuels a cycle of belief in antibiotics, subsequent reattendance, and further antibiotic request and use. Delayed prescribing appears to be as effective as not prescribing antibiotics in changing beliefs, and it also changes subsequent consultation behavior. Delayed prescribing has similar or lower rates of reattendance when compared with not prescribing. Third, delayed prescribing achieves acceptable symptom control. Previous systematic reviews of delayed prescribing have called for more evidence on this point. Most trials, including the trial by Spiro

Information Leaflet and Antibiotic Prescribing Strategies for Acute Lower Respiratory Tract Infection: A Randomized, Controlled Trial

Purpose of the Study. Acute lower respiratory tract infection is the most common condition treated in primary care. Many physicians still prescribe antibiotics; however, systematic reviews of the use of antibiotics are small and have diverse conclusions. This study evaluated the effectiveness of 3 prescribing strategies and an information leaflet for acute lower respiratory tract infection. Study Population. A randomized, controlled trial conducted from August 18, 1998, to July 30, 2003, of 807 patients presenting to a primary care setting with acute uncomplicated lower respiratory tract infection. Patients were assigned to 1 of 6 groups by a factorial design: leaflet or no leaflet and 1 of 3 antibiotic groups (immediate antibiotics, no offer of antibiotics, and delayed antibiotics). Methods. Three strategies, immediate antibiotics (n = 262), a delayed antibiotic prescription (n = 272), and no offer of antibiotics (n = 273), were prescribed. Approximately half of the patients in each group received an information leaflet (129 for immediate antibiotics, 136 for delayed antibiotic prescription, and 140 for no antibiotics). Results. A total of 562 patients (70%) returned complete diaries, and 78 (10%) provided information about both symptom duration and severity. Cough rated at least “a slight problem” lasted a mean of 11.7 days (25% of the patients had a cough lasting ≥17 days). An information leaflet had no effect on the main outcomes. Compared with no offer of antibiotics, other strategies did not alter cough duration (delayed prescription, 0.75 days; 95% confidence interval: −0.37–1.88; immediate prescription, 0.11 days; 95% confidence interval: −1.01–1.24) or other primary outcomes. Compared with those in the immediate-antibiotic group, slightly fewer patients in the delayed-prescription and control groups used antibiotics (96%, 20%, and 16%, respectively; P &amp;lt; .001), fewer patients were “very satisfied” (86%, 77%, and 72%, respectively; P = .005), and fewer patients believed in the effectiveness of antibiotics (75%, 40%, and 47%, respectively; P &amp;lt; .001). There were lower reattendances within a month with antibiotics (mean attendances for no antibiotics: 0.19; delayed prescription: 0.12; immediate prescription: 0.11; P = .04) and higher attendance with a leaflet (mean attendances for no leaflet: 0.11; mean attendances for leaflet: 0.17; P = .02). Conclusions. No offer or a delayed offer of antibiotics for acute uncomplicated lower respiratory tract infection is acceptable, associated with little difference in symptom resolution, and is likely to considerably reduce antibiotic use and beliefs in the effectiveness of antibiotics. Reviewer Comments. This is good that we do not need yet another patient-information leaflet. I have always liked the “delayed-offer” approach, because it is a compromise to the patient, and most of the time they get better and never need the drug.

Information Leaflet and Antibiotic Prescribing Strategies for Acute Lower Respiratory Tract Infection

Acute lower respiratory tract infection is the most common condition treated in primary care. Many physicians still prescribe antibiotics; however, systematic reviews of the use of antibiotics are small and have diverse conclusions. To estimate the effectiveness of 3 prescribing strategies and an information leaflet for acute lower respiratory tract infection. A randomized controlled trial conducted from August 18, 1998, to July 30, 2003, of 807 patients presenting in a primary care setting with acute uncomplicated lower respiratory tract infection. Patients were assigned to 1 of 6 groups by a factorial design: leaflet or no leaflet and 1 of 3 antibiotic groups (immediate antibiotics, no offer of antibiotics, and delayed antibiotics). Three strategies, immediate antibiotics (n = 262), a delayed antibiotic prescription (n = 272), and no offer of antibiotics (n = 273), were prescribed. Approximately half of each group received an information leaflet (129 for immediate antibiotics, 136 for delayed antibiotic prescription, and 140 for no antibiotics). Symptom duration and severity. A total of 562 patients (70%) returned complete diaries and 78 (10%) provided information about both symptom duration and severity. Cough rated at least "a slight problem" lasted a mean of 11.7 days (25% of patients had a cough lasting > or =17 days). An information leaflet had no effect on the main outcomes. Compared with no offer of antibiotics, other strategies did not alter cough duration (delayed, 0.75 days; 95% confidence intervals [CI], -0.37 to 1.88; immediate, 0.11 days; 95% CI, -1.01 to 1.24) or other primary outcomes. Compared with the immediate antibiotic group, slightly fewer patients in the delayed and control groups used antibiotics (96%, 20%, and 16%, respectively; P<.001), fewer patients were "very satisfied" (86%, 77%, and 72%, respectively; P = .005), and fewer patients believed in the effectiveness of antibiotics (75%, 40%, and 47%, respectively; P<.001). There were lower reattendances within a month with antibiotics (mean attendances for no antibiotics, 0.19; delayed, 0.12; and immediate, 0.11; P = .04) and higher attendance with a leaflet (mean attendances for no leaflet, 0.11; and leaflet, 0.17; P = .02). No offer or a delayed offer of antibiotics for acute uncomplicated lower respiratory tract infection is acceptable, associated with little difference in symptom resolution, and is likely to considerably reduce antibiotic use and beliefs in the effectiveness of antibiotics.