Withholding, delaying antibiotics for simple respiratory infections had similar outcomes as immediate prescriptions

Not prescribing antibiotics or delaying prescriptions for uncomplicated acute sore throats and other respiratory infections resulted in fewer than 40% of patients using antibiotics and similar symptomatic outcomes versus offering immediate prescriptions, a study found.

Researchers in the United Kingdom conducted a pragmatic, randomized trial among 889 patients ages 3 years and over with acute respiratory tract infection (acute cold, influenza, sore throat, otitis media, sinusitis, croup or lower respiratory tract infection) who were recruited between March 2010 and March 2012 by 53 clinicians in 25 general practices.

Patients judged not to need immediate antibiotics were randomly assigned to 4 strategies of delayed prescription: recontact the clinic to request a prescription, be given a postdated prescription that could be filled later, allow the patient to pick up a prescription (collect) at the clinic at their discretion, or be given a valid prescription to be filled at the patient's choosing. During the trial, a strategy of no antibiotic prescription was added as another randomized comparison.

Symptom severity was self-measured and recorded for 2 weeks in symptom diaries at the end of each day until symptoms returned to normal. Symptoms included feeling generally unwell, sleep disturbance, fever, interference with normal activities, sore throat, cough, shortness of breath, facial or sinus pain, earache, and runny or blocked nose and were ranked from 0 (no problem) to 6 (as bad as it could be).

Results appeared online March 6 at BMJ.

Of the 889 patients, 333 (37%) were found to need immediate antibiotics and 556 (63%) entered the randomized trial. In the no-prescription and delayed-prescription groups, there was no significant effect of strategy on symptom severity (P=0.625), duration of illness (P=0.368), and small differences of 0.1°C in temperature control (P=0.035).

Antibiotic use did not differ significantly between strategies (P=0.292), with the lowest use (26%; 26 of 99 patients) reported in the no-prescription arm and an average of 37% (134 of 367 patients) taking antibiotics in the delayed arms, with rates varying from 33% (28 of 85 patients) in the collected-prescription arm to 39% (35 of 89 patients) in the group that received a prescription to fill if they chose. Belief in the effectiveness of antibiotics was strong and not significantly different among the groups (P=0.805). Patient satisfaction also did not differ significantly. Reconsultations during 1 month of follow-up and after that month were similar in all groups.

After inclusion of the nonrandomized immediate-prescription group, there was no significant effect of antibiotic prescribing strategy on symptom severity (P=0.543), duration (P=0.424), or temperature (P=0.176). Antibiotic use differed significantly (P<0.001), with 97% of patients (270 of 278 patients) reporting antibiotic use in the immediate arm. More patients in that group believed antibiotics were very effective (93% [168 of 180 patients]; P<0.01 compared to other groups) despite immediate prescription of antibiotics having no effect on symptom control or duration.

The researchers noted that if clear advice is given to patients, there is probably little difference between the different delayed-prescription strategies. Any strategy of delayed prescribing is likely to result in fewer than 40% of patients using antibiotics, they said.

“This finding contrasts both health professionals' behavior in commonly requiring immediate antibiotics, and the persistently strong beliefs patients have in the effectiveness of antibiotics,” the authors wrote. “The different ways of using delayed prescription, when the same structured approach is used, had more similar outcomes than previous trial data suggest, although the collection approach performed well on most criteria.”