Do delayed prescriptions help reduce antibiotic use?
Cliodna is Head of Primary Care Unit for the National Infection Service, Public Health England, Honorary Visiting Professor for Cardiff University, and Consultant Medical Microbiologist.
There has been much discussion about the use of giving so called back-up or delayed antibiotic prescriptions in acute uncomplicated infections, to reduce antibiotic use and reduce patient expectations. Delayed prescriptions mean a patient may be asked to wait (usually 24-48 hours) after a clinical visit before claiming his or her prescription, allowing time to rule unnecessary use of antibiotics in case of a viral infection. There are several ways to give a delayed antibiotic prescription, including:
- writing a post-dated prescription
- re-contacting a patient after a clinical visit
- providing a prescription and giving a verbal order to fill the prescription after a predetermined length of time if symptoms do not improve.
A detailed review of many studies in primary care has shown the benefits of this approach, in decreasing antibiotic use without increasing complications in patients.
The figure shows a study in acute sore throat. Patients in 11 English GP practices were randomised into immediate antibiotics (in red), back-up antibiotics (in yellow) and no antibiotics groups (in green).
There was no difference in recovery rates and high levels of satisfaction with all strategies. Compared to immediate antibiotics, those given no antibiotics or back-up antibiotics had a reduction in belief in antibiotics for sore throat and were less likely to visit the GP again for similar symptoms.
A more recent study of acute sore throat (the DESCARTE study) in fact showed that complications in those who received immediate prescriptions were similar to those receiving a back-up prescription, even though 30% did not collect the prescription. Complications were higher in the no antibiotic group.
The back-up prescription is especially useful to give to patients who have a high expectation for antibiotics, and can be accompanied by a patient leaflet which includes advice on self-care and when to contact a health professional if symptoms worsen. This leaflet is available on many GP computer systems.
This survey of the public showed that 4% of the public in 2014 reported being given a back-up antibiotic prescription, so the strategy is being used by GPs. Of those participants given a delayed prescription from their surgery, about 30% of participants do not collect the antibiotic. So this is a good technique, especially in patients with high expectations.
A public survey in 2014 showed that 40% of the public were in favour of the use of delayed antibiotics – but many are unsure or opposed, so we do need to explain the purpose of this approach carefully to patients. Furthermore, many patients misunderstood the term delayed antibiotics and thought it meant you still took the antibiotic, but later. Therefore the term ‘back-up antibiotics’ is better and more understood by patients.
Public Health England (PHE) and the British Society for Antimicrobial Chemotherapy (BSAC) have worked with primary care colleagues to develop a series of 7 free TARGET antibiotics webinars highlighting key easy actions people can take to help improve antibiotic prescribing, and at the same time improve patient experience and self-care.
2 November: Introductory case studies
9 November: Assessing the need for antibiotics
16 November: Managing patient expectations
23 November: Back-up prescriptions
30 November: Prescribing in UTI
7 December: Antibiotics for children
14 December: Common practice approach
The webinars will be held each Wednesday from 13:30 – 14:15 (UK time) with content made available after the session. Access the webinars here.
The TARGET Toolkit
TARGET stands for: Treat Antibiotics Responsibly, Guidance, Education, Tools. The TARGET Antibiotics Toolkit aims to help influence primary care prescribers’ and patients’ personal attitudes, social norms and perceived barriers to optimal antibiotic prescribing. The TARGET Antibiotics Toolkit is designed to be used by the whole primary care team within the GP practice or out of hours setting. These resources can be used flexibly, either as standalone materials or as part of the integrated package. The TARGET Antibiotics Toolkit development was led by Professor Cliodna McNulty in close collaboration with the RCGP, BSAC and other professional societies with an interest in infections and antimicrobial resistance. Cliodna continues as Public Health England clinical lead for this toolkit, and is currently leading the development of a TARGET-webinar series with the BSAC.