Do Delayed Prescriptions Reduce the Use of Antibiotics for the Common Cold?

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Original Research

Do Delayed Prescriptions Reduce the Use of Antibiotics for the Common Cold?

J Fam Pract. 2002 April;51(4):324-328

By

Arroll

B., MBChB, PhD

A Single-Blind Controlled Trial

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References

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ABSTRACT

OBJECTIVE: To test the use of a delayed prescription compared with instructions to take antibiotics immediately in patients presenting to family physicians with upper respiratory tract infections (common colds).

STUDY DESIGN: Randomized controlled single-blind study.

POPULATION: Subjects were 129 patients presenting with the common cold who requested antibiotics or whose physicians thought they wanted them. All patients were in a family practice in Auckland, New Zealand, consisting of 15 physicians (9 male, 6 female) who had completed medical school between 1973 and 1992.

OUTCOMES MEASURED: Outcomes were antibiotic use (taking at least 1 dose of the antibiotic), symptom scores, and responses to the satisfaction questions asked at the end of the study.

RESULTS: Patients in the delayed-prescription group were less likely to use antibiotics (48%, 95% CI, 35%-60%) than were those instructed to take antibiotics immediately (89%, 95% CI, 76%-94%). Daily body temperature was higher in the immediate-prescription group. The lack of difference in the symptom score between the 2 groups suggests that there is no danger in delaying antibiotic prescriptions for the common cold.

CONCLUSIONS: Delayed prescriptions are a safe and effective means of reducing antibiotic consumption in patients with the common cold. Clarification of patient expectations for antibiotics may result in a lower prescription rate. When the patient demands a prescription, delaying its delivery has the potential to provide gentle education.

KEY POINTS FOR CLINICIANS

Delaying the prescription of antibiotics reduces antibiotic intake in patients who insist on taking antibiotics for the common cold.
Giving a delayed prescription and asking the patient to return to the office to fill it may reduce antibiotic consumption further.

Antibiotics continue to be commonly used to treat the common cold^1-3 despite longstanding doubts about their efficacy^4,5 or ability to prevent complications.⁶ Upper respiratory tract infection (URTI) is the most common reason for a new consultation in family practice and the second most common reason for the prescribing of an antibiotic.⁷ Reported prescription rates for antibiotics for treating the common cold range from 17% to 60% in the United Kingdom and United States and 78% in New Zealand.^1,8 Ineffective but widespread use of antibiotics is not only a poor use of health care funds but also a cause of morbidity (from adverse effects) and the development of resistant strains of bacteria.^8-10

A promising technique to reduce antibiotic use is the delayed prescription. The only published randomized controlled trials of delayed prescription use examined its effect for the treatment of sore throat, acute childhood otitis media, and cough.^11-13 In the sore throat study, antibiotics were used by 99% of a group given antibiotics, by 13% of a group not offered any, and 31% of a group given a prescription to be taken after 3 days if symptoms persisted. The authors of the otitis media study noted a 66% reduction of antibiotic use in the delayed-prescription group, who had more symptoms, signs, and sleepless nights than the “take-now” group. In the study with acute cough, the use of antibiotics was reduced by 55% in the group with delayed prescriptions. Our study, undertaken in winter 2000, tested the use of a delayed prescription versus instructions to take antibiotics immediately in patients presenting to general practitioners with URTIs.

Methods

The 15 family physicians (FPs) who recruited patients for this study were selected primarily from a group who had reported in a previous study that they frequently gave delayed prescriptions to patients.¹⁴ Ethical approval was given by the Auckland Ethics Committee.

Inclusion and exclusion criteria

Patients of any age were eligible if they presented to their FP with a new case of the common cold and either the FP thought the patient wanted antibiotics or the patient stated that desire. For young children, the parents indicated whether or not they wanted antibiotics. FPs were provided with the diagnostic criteria for URTI from the International Classification of Health Problems in Primary Care (ICHPPC-2), which defines an URTI as including the presence of acute inflammation of the nasal or pharyngeal mucosa in the absence of other specifically defined respiratory infection.¹⁵

Patients were excluded if they had suspected streptococcal tonsillitis, sinusitis, bronchitis, or pneumonia. Also excluded were patients with lower respiratory signs, those who needed an x-ray, those with a past history of rheumatic fever, and those who had experienced a serious illness or any antibiotic treatment in the previous 2 weeks. Throat cultures were not required. Eligible patients were invited to participate and signed an informed consent form. Ideally, the offer to join the study was to be made to consecutive patients, but this did not occur in all practices.