Effect of antibiotic prescribing strategies and an information leaflet on longer-term reconsultation for acute lower respiratory tract infection

Abstract

Limited evidence suggests that delayed prescribing may influence future consultation behaviour. AimTo assess the effects of antibiotic prescribing strategy on reconsultation in the year following presentation with acute lower respiratory tract infection (LRTI). Design of studyBalanced factorial randomised trial. SettingPrimary care. MethodEight hundred and seven subjects, aged ≥3 years, had acute illness presenting with cough as the main symptom, plus at least one symptom or sign from sputum, chest pain, dyspnoea or wheeze. The subjects were randomised to one of three prescribing strategies (antibiotics, delayed antibiotic, no antibiotic) and a leaflet. Prior antibiotic use and reconsultation were assessed by medical record review. ResultsPatients who had been prescribed antibiotic for cough in the previous 2 years were much more likely to reconsult (incidence rate ratio [IRR] = 2.55, 95% confidence interval [CI] = 1.62 to 4.01) and use of a delayed prescription strategy is associated with reduced reconsultation in this group. In those with prior antibiotic exposure, there was a 34% reduction in consultation rate in the no antibiotic group (IRR = 0.66, 0.30 to 1.44, P = 0.295) and a 78% reduction for the delayed antibiotic group (IRR = 0.22, 0.10 to 0.49, P<0.001) when compared with those given immediate antibiotics. This effect was not observed in patients who had not been prescribed antibiotics in the previous 2 years; there was no reduction in consultations in the no antibiotic group (IRR = 1.23, 0.79 to 1.92, P = 0.358) or the delayed antibiotic group (1.19, 0.78 to 1.80, P = 0.426). There was an increase in consultation rate with an information leaflet (IRR = 1.27, 0.86 to 1.87, P = 0.229). Past attendance with cough, or past attendance with other respiratory illness and smoking, also predicted reconsultation with cough. ConclusionDelayed antibiotic prescribing for LRTI appears effective in modifying reconsultation behaviour, particularly in those with a prior history of antibiotic prescription for LRTI. Keywordsanti-bacterial agents; primary health care; referral and consultation; respiratory tract infections. INTRODUCTIONPreliminary evidence in acute sore throat suggests that delayed prescribing may influence future consultation behaviour.Those with a recent history of antibiotic prescribing were much more than twice as likely to reconsult in the year following the index consultation with acute lower respiratory infection (LRTI). They showed substantial (78%) reduction in consultation following delayed prescribing compared with immediate prescribing.Over time, utilising a delayed prescribing strategy is likely to result in sustained reduction in consultation for LRTI. BackgroundAcute respiratory illness is the most common condition managed in primary care, and antibiotics are widely prescribed for LRTI despite limited evidence of benefit.

A study of antibiotic prescribing: the experience of Lithuanian and Russian GPs

“…Norway), delayed prescription is perceived by GPs as a practical solution that could help to meet patient needs and avoid seeking after-hours care if their condition worsens [53]. Moreover, a randomised trial [54] demonstrated that delayed prescription is effective in modifying behaviour during follow-up consultations, leading to a lower rate of follow-up consultations among those that had delayed prescriptions as compared to those prescribed right away. Ultimately, formalizing and promoting a delayed approach could become an integral part of an effective rational antibiotic use policy.…”

Predictors of patient-initiated reconsultation for lower respiratory tract infections in general practice

“…The delayed prescription strategy, commonly used in the UK but not in the Netherlands, might be particularly suited to preventing these reconsultations without unnecessarily increasing antibiotic prescribing in this group of patients with intermediately elevated CRP values. 10 All together, this stresses the importance of explanation provided to the patient on the implications of CRP values.…”

“…A recent study shows that patients who had been prescribed antibiotics for cough in the previous 2 years were much more likely to reconsult for LRTI. 10 Fewer reconsultations for LRTI decreases workload and will decrease antibiotic prescribing for patients who are at particular risk of unnecessary antibiotic prescribing during reconsultations. Nearly half of all patients were prescribed antibiotics during patient-initiated reconsultations, despite evidence suggesting that they are unlikely to benefit at the point of reconsultation, except for a minority of patients with evident deteriorating illness.…”

Effectiveness of physician-targeted interventions to improve antibiotic use for respiratory tract infections

“…1 Non-indicated use of antibiotics is furthermore related to unnecessary exposure to adverse effects, costs and patients' re-consultation. 2,3 There is growing concern that therapeutic options become limited if resistance rates continue to rise. The most effective strategy for combating antimicrobial resistance is decreasing antibiotic use.…”