Delayed Prescriptions for Reducing Antibiotic Use
de la Poza Abad M, Mas Dalmau G, Moreno Bakedano M, et al; Delayed Antibiotic Prescription (DAP) Group. Prescription strategies in acute uncomplicated respiratory infections: a randomized clinical trial. JAMA Intern Med 2016;176:21–9.
Commentary
Acute respiratory infections are a common reasons for physician visits. These infections tend to be self-limiting and overuse of antibiotics for these infections is widespread. Approximately 60% of patients with a sore throat and ~70% of patients with acute uncomplicated bronchitis receive antibiotic prescriptions despite the literature suggesting no or limited benefit [2,3].Antibiotic resistance is a growing problem and the main cause of this problem is misuse of antibiotics.
Often physicians feel pressured into prescribing anti-biotics due to patient expectation and patient satisfaction metrics. In the face of the critical need to reduce overuse, delayed antibiotic prescribing strategies offers a compromise between immediate and no prescription [4]. Delayed prescribing strategies have been evaluated previously [5–8], with findings suggesting they do reduce antibiotic use. This study strengthens the evidence base supporting the delayed strategy.
This study has a few limitations. The sample size was small, and symptom data was obtained via patient self-report. In addition, the randomization procedure was not described. However, the investigators were able to achieve good patient retention, with very few patients lost to follow-up. The investigators used an intention to treat analysis; thus, the estimate of treatment effect size can be considered conservative.
In terms of baseline characteristics of the study participants, there was a lower overall education level, fewer smokers, and less respiratory comorbidity (defined as only cardiovascular comorbidity [P = 0.12] and diabetes [P = 0.19]) in the patient-led group. Otherwise, groups were very well-matched. Most patients in the study had pharyngitis and bronchitis, limiting the inferences for patients with rhinosinusitis or exacerbation of mild-to-moderate COPD.
Applications for Clinical Practice
Delayed antibiotic prescribing for acute uncomplicated respiratory infections appears to be an acceptable strategy for reducing the overuse of antibiotics. As patients may lack knowledge of this prescribing strategy [9], clinicians may need to spend time explaining the concept. Using the term “back-up antibiotics” instead of “delayed prescription” [10] may help to increase patients’ understanding and acceptance.
—Ajay Dharod, MD
