17 October 2011
A qualitative study provides insight into the views of some prescribers in the north west of England on the usefulness of delayed antibiotic prescribing as a strategy for reducing antibiotic prescribing in patients with acute respiratory tract infections (RTIs). However, as recommended by NICE, the use of delayed prescriptions remains an effective tool in the management of self-limiting infections.
Level of evidence:
Level 3 (other evidence) according to the SORT criteria.
This study is interpreted by the investigators as questioning the position of the delayed prescribing of antibiotics within the NICE clinical guideline for RTIs. However, in view of its limitations and contrasting evidence from some other studies, prescribers should not be deflected from considering a delayed prescribing strategy as an option for patients with self-limiting RTIs according to the guideline (NICE clinical guideline 69: prescribing of antibiotics for self-limiting RTIs in adults and children). Following clinical assessment, NICE stresses the need to address patients, or parents’/carer’s concerns and expectations when agreeing the use of one of three antibiotic strategies (no prescribing, delayed prescribing or immediate prescribing).
NICE recommends agreeing a no antibiotic or delayed antibiotic prescribing strategy for patients with acute otitis media, acute sore throat/pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis or acute cough/acute bronchitis. However, an immediate prescribing strategy can also be considered for certain subgroups (children younger than 2 years with bilateral acute otitis media; children with otorrhoea who have acute otitis media; patients with acute sore throat/acute tonsillitis when three or more Centor criteria are present) depending on the severity of the RTI.
Immediate antibiotic prescribing and/or further investigation and management is appropriate for patients at risk of complications. Where a patient is not at risk of developing complications, either a no prescribing or a delayed prescribing strategy can be offered.
When a delayed antibiotic prescribing strategy is adopted, patients should be offered:
- reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash
- advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of the illness or if a significant worsening of symptoms occurs
- advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription.
A delayed prescription with instructions can either be given to the patient or left at an agreed location to be collected at a later date.
What is the background to this?
Acute RTIs (e.g. acute otitis media, acute cough/acute bronchitis, acute sore throat/acute pharyngitis/acute tonsillitis, acute rhinosinusitis and the common cold) are a major cause of primary care consultations in the UK. There is evidence from randomised placebo-controlled trials that antibiotics have limited efficacy in treating a large proportion of RTIs in adults and children (see NICE Full Guideline). Unnecessary use of antibiotics is of concern as it can encourage antibiotic resistance, adverse drug reactions and medicalisation of what is largely a self-limiting disease, where complications are rare if antibiotics are withheld.
The NICE guideline on the prescribing of antibiotics for self-limiting RTIs in adults and children (aged over 3 months) in primary care was issued in 2008. The decision agreed between healthcare professional and patient on which antibiotic prescribing strategy to adopt depends on both the healthcare professional’s assessment of the risk of complications if antibiotics are withheld and the patient’s expectations regarding an antibiotic prescription. The perceived advantages of delayed prescribing as a strategy over no prescribing are that it offers a ‘safety net’ for the small proportion of patients who develop a complication, and that a patient expecting antibiotics may be more likely to agree with this course of action rather than with no prescribing.
The authors of the present study carried out a qualitative study of GPs and non-medical prescribers in the north west of England (interviews and focus groups) to investigate how delayed prescribing was being used by UK primary care prescribers and to identify the perceived benefits and limitations of the approach.
Prescribers felt that delayed-prescribing presents a mixed message to patients about the efficacy of antibiotics for self-limiting RTIs and creates discomfort through giving patients clinical control over their condition. Although often used to manage diagnostic uncertainty, many prescribers preferred patients to reconsult under these circumstances. Delayed prescribing was also used to avoid conflict, although some had found more effective strategies to achieve this.
Where a delayed strategy was used prescribers preferred to give the patients a prescription straight away, with instructions how to get it dispensed (rather than using post dating or call and collect) as this was felt to communicate trust and be less likely to lead to confrontation. However, as the patient could collect the prescription straight away the prescribers felt this was unlikely to lead to a reduction in antibiotic use and future expectations for antibiotics.
The authors concluded that delayed prescribing was not considered to be a helpful strategy for managing patients with self-limiting RTIs within primary care. Although delayed prescribing may serve as a useful safety net in case a medical situation deteriorates, it was not considered the best way to reduce antibiotic prescribing. The authors suggest that other ways of communicating empathy, addressing patient beliefs, and encouraging self-management should be employed, without recourse to the use of antibiotics.
How does this relate to other studies?
Although other studies have been carried out on this issue, the investigators claim that this is the first study to explore UK primary care prescribers’ perceptions of the NICE recommended delayed prescribing strategy.
A Cochrane review (2007), evaluating clinical outcomes, adverse effects, antibiotic use and patients satisfaction associated with delayed prescribing compared to immediate prescribing or no antibiotic prescribing for RTIs, found that there was no difference for most clinical outcomes between strategies. Patient satisfaction was slightly reduced in the delayed antibiotic group (87% satisfied) compared to the immediate antibiotic group (92% satisfied) but no different from the no antibiotic group.
The evidence review carried out for the NICE guideline (2008), identified two studies of patients with upper RTIs that considered patient preferences regarding antibiotic management strategies for RTIs, and concluded that “for patients who were expecting to receive immediate antibiotics during consultation, over 90% of those who then received a delayed prescription for acute upper RTIs were satisfied and would choose to receive a delayed prescription again in the future.”
A Norwegian qualitative study (2010) explored GPs’ views on and experiences with delayed prescribing in patients with acute RTIs. Not all GPs endorsed delayed prescribing; however, it was considered a feasible approach for managing patients with early symptoms of mild upper RTIs of a possible bacterial origin. GPs who endorsed the strategy emphasised shared decision making and the creation of opportunities for educating patients, whereas GPs who were negative applied the strategy mainly when being pressed to prescribe. For issuing a wait-and-see prescription, the GPs required that the patient was `knowledgeable’, able to understand the indications for antibiotics, and motivated for shared decision making. GPs emphasised that patients should be informed thoroughly when receiving a wait-and-see prescription.
A subsequent Norwegian questionnaire survey (2011) of GPs issuing a wait-and-see prescription for RTIs found that most patients and GPs were satisfied with a delayed antibiotic prescribing strategy. In 69% of cases, the GP found delayed prescribing a very reasonable strategy, and 89% of patients expressed a preference to receive a wait-and-see prescription in a similar situation in the future.
As presented by the investigators, the present study apparently questions the use of delayed antibiotic prescribing as a means of reducing antibiotic prescribing for acute RTIs. Although recognising that it may have a useful role as a safety net, they suggest that where immediate antibiotic prescribing is not indicated then it is better to use a no prescribing strategy, with reconsultation if symptoms do not resolve by themselves, and using other means to reassure and encourage patients that an immediate prescription for antibiotics is not necessary. However, such an approach is consistent with the NICE guideline approach, which suggests this alongside delayed prescribing, as one of the options that can be chosen, after taking into account parents’/carer’s concerns and expectations. As well as providing a safety net for the small number of patients who develop a complication, delayed prescribing provides a means for managing patient expectation for a prescription, while providing a means for reducing antibiotic use.
While offering some insight into the views and use of delayed prescribing, and offering food for thought to both guideline developers and prescribers, the study provides no good reason to deviate from existing NICE guidance. The results of this study can not be extrapolated to the UK as a whole with any certainty in view of its qualitative nature, its small size and restriction to just one region of England. Only 13% of the prescribers approached to participate in the study agreed to take part, and it is not known how representative the views of those interviewed were of the entire population of the north west of England, yet alone the UK as a whole. Although sound qualitative methodology was used for the study, as pointed out by the investigators, interviewer influence can not be ruled out, and they suggest that to address these issues future studies should aim to observe prescribers during consultations. Its findings also need to be interpreted cautiously in the context of other studies, some of which appear to give contrasting results.
Peters S, Rowbotham S, Chisholm A, et al. Managing self-limiting respiratory tract infections: a qualitative study of the usefulness of the delayed prescribing strategy. BJGP 20011:61;e579–e589
Qualitative review and focus group study in UK primary care settings.
Data were gathered through semi-structured interviews (n=49) and six focus groups with GPs, trainee GPs, and nurse prescribers. An iterative analysis approach, using grounded theory principles, was used to generate themes from the dataset.
Supported by a grant from the British Society for Antimicrobial Chemotherapy.
Further information can be found on NHS Evidence and in the common infections – respiratory tract e-learning section of the NPC website.
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