Does Delaying Antibiotics Work?

To reduce the use of antibiotics for respiratory tract infections, some general practitioners either don’t prescribe antibiotics or delay their use by, for example, asking the patient to wait. But some reviews have suggested that delaying prescriptions can result in worse symptom control than would the immediate use of antibiotics and could lead to higher use of antibiotics than would a no-prescription policy.

The different methods of delaying prescriptions haven’t been compared directly—is there a real benefit to delay? To find out, researchers from the University of Southampton in the United Kingdom conducted a pragmatic, open factorial trial of delayed antibiotic strategies. To their knowledge, they say, it is one of the largest so far to assess the effect of different antibiotic-prescribing strategies on symptom control and antibiotic use and the only trial so far to compare several commonly used methods of delaying antibiotic prescription.

In the study, 53 physicians and nurses in 25 practices decided in negotiation with patients whether immediate antibiotics were needed. If not, patients were randomly assigned to 1 of 4 delayed-prescribing groups: recontact for a prescription, postdated prescription, collection of the prescription, or patient led (the patient was given the prescription but advised to wait to fill it). The main groups were divided into 12 subgroups, according to 3 factors: antipyretic regimens, regular antipyretic vs “as required” dosing, and steam inhalation advice vs no advice about steam. During the study, the researchers added a strategy of “no antibiotic prescription” as another randomized comparison.

The primary outcome was symptom severity measured at the end of each day during days 2 to 4 (when symptoms of all respiratory infections are at their worst) of a 2-week symptom diary. Secondary outcomes included any antibiotic use in the 14 days after recruitment, return with worsening symptoms, and complications.

In all, 264 patients completed the main diary and documented taking antibiotics. The median day for starting was day 4 for delayed-prescription strategies and day 1 for the immediate-prescription group. In the randomized groups (no prescription and delayed-prescription strategies), the researchers observed no significant effect of strategy on symptom severity. Antibiotic use did not differ significantly between strategies. The delayed groups reported slightly higher antibiotic use than that of the no-prescription group; 26% of patients not initially prescribed antibiotics used them, compared with roughly one-third of patients given a delayed prescription. Satisfaction was higher with the patient-led and collection approaches.

Complications were slightly more common in the no-prescription group (3 of 122 patients [2.5%]), compared with the delayed-strategy groups (average 6 of 432 patients [1.4%]), and similar to the immediate-prescription group (8 of 326 patients [2.5%]).

Finding little difference in symptom control between the strategies of no prescription, immediate prescription, or delayed prescription, the researchers say, “contrasts both health professionals’ behavior in commonly requiring immediate antibiotics, and the persistently strong beliefs patients have in the effectiveness of antibiotics.”

The study was designed to be pragmatic: Patients were free to not comply with advice, but compliance was probably reasonable, the researchers say. Most patients who were asked to delay using antibiotics did not use them, and those who used antibiotics, on average, delayed for several days. Such advice is not normally measured or assessed in trials of antibiotic strategies, the researchers note. They say one of the strengths of their study is that they assessed interactions between advice about symptoms and antibiotic-prescribing strategies.

The good symptom control in the study could indicate that all patients were given structured advice about analgesic use. With “clear guidance,” the researchers conclude, any strategy of delayed prescribing is likely to result in less than 40% of patients using antibiotics.

Source
Little P, Moore M, Kelly J, et al; PIPS Investigators. BMJ. 2014;348:g1606.
doi: 10.1136/bmj.g1606.