Getting to grips with antibiotic overprescribing

A delayed prescription is one that is given to a patient or patient’s carer for an appropriate antibiotic (in the case of this research). It is not meant to be used unless  symptoms worsen or do not start to settle in the expected timescale. 

The delayed prescription has often been described as a method of compromise in situations where the doctor feels there is no clinical indication for an antibiotic, but where the patient requests one. It can also provide a safety net for the doctor, as we do not know who is at risk of subsequently developing rare but important complications of infection. 

Respiratory tract infections (RTIs) account for 60% of all antibiotic prescribing in primary care. NICE guidelines on prescribing antibiotics for minor respiratory illnesses were introduced in 2008.¹

Three different management strategies for antibiotics were outlined: no antibiotic prescribing, delayed prescribing and immediate prescribing. However, not all GPs endorse their use. 

Insights obtained from qualitative research show that some GPs had concerns about possibly missing or masking serious illness, leading to medico-legal issues. Some also worried that their patients may consider them incompetent.²

Our specific aims were to examine the attitudes and experiences of GPs in the mid-western region towards the use of antibiotics in general practice.

Methods

We applied for ethical approval to the ICGP ethics committee and were granted approval in October 2010. 

The HSE Primary Care Unit supplied us with a list of all 215 private and GMS GPs in the mid-western area including Clare, Limerick and North Tipperary. 

We used a sample population of 141 doctors from the mid-western region for this cross-sectional study. We randomly selected 43 doctors in Limerick city (30% 43/141), 34 doctors in Co Limerick (24% 34/141), 39 doctors in Co Clare (28% 39/141) and 25 doctors in North Tipperary (18% 25/141) to roughly equate to the geographical spread of GPs throughout the region. 

Data was collected by postal questionnaire over a five-week period from October 20, 2010 to November 24,  2010. Each GP received an explanatory letter with brief introduction, questionnaire and stamped addressed envelope for return. All responses were anonymous.

Results

A total of 141 questionnaires were posted, 103 responses were received (response rate of 73%). All replies were complete and suitable for interpretation. 

Attitudes and experiences

We found that 31% of GPs strongly agreed and 63% agreed (majority) that antibiotics are overused in general practice. Two per cent of GPs remained neutral, while 4% disagreed that antibiotics are overused in general practice. 

Four per cent of GPs felt under pressure to prescribe an antibiotic several times a day; 34% felt under pressure to prescribe an antibiotic at least once a day; 39% felt under pressure to prescribe an antibiotic once a week; 18% felt under pressure to prescribe an antibiotic once a month and 5% felt under pressure to prescribe an antibiotic less than once a month. 

All 103 GPs who responded were familiar with the term ‘delayed’ or ‘deferred’ prescriptions; 19% strongly agreed and 40% agreed that delayed prescriptions are a safe prescribing strategy; 30% remained neutral; 7% disagreed and 4% strongly disagreed that delayed prescriptions is a safe prescribing strategy. 

A total of 31% of GPs strongly agreed and 51% agreed that delayed prescriptions have the potential to reduce antibiotic use; 11% remained neutral; 4% disagreed and 3% strongly disagreed that delayed prescriptions have the potential to reduce antibiotic use. 

Five per cent of GPs strongly agreed and 21% agreed that giving delayed prescriptions increases the duration of the consultation; 30% remained neutral; 32% disagreed and 12% strongly disagreed that giving delayed prescriptions increases the duration of the consultation. 

Twenty-six per cent of GPs strongly agreed and 47% agreed that delayed prescriptions decrease the likelihood of return visit in the same illness; 13% remained neutral; 11% disagreed that delayed prescriptions decrease the likelihood of return visit in the same illness, while 3% strongly disagreed.

A total of 30% of GPs strongly agreed and 53% agreed that delayed prescriptions help to involve patients in managing their own illness; 9% remained neutral; 5% disagreed that delayed prescriptions help to involve patients in managing their own illness, while 3% strongly disagreed.

Three per cent of GPs strongly agreed that patients find delayed prescriptions confusing (minority); 7% agreed; 30% remained neutral; 45% disagreed (majority) and 15% strongly disagreed.

Of GPs surveyed, 4.9% use delayed prescriptions several times a day; 33% use them at least once a day; 39.8% once a week; 12.6% once a month, while 9.7% never use delayed prescriptions or use them less than once a month.

The majority of GPs surveyed (32%) disagreed that giving a delayed prescription increases the duration of the consultation; 47% agreed and 26% strongly agreed that delayed prescribing was seen to decrease the likelihood of return visit in the same illness.

Discussion

The first RCT of delayed prescriptions for respiratory symptoms was undertaken by Little et al in 1997. The delayed group filled only 31% of the antibiotic prescriptions with no apparent serious harm.³ A further study by Little et al showed that more of those initially prescribed antibiotics returned to the surgery with sore throat (38% v 27% in the other two groups).⁴

A Cochrane review by Arnold et al of interventions to improve antibiotic prescribing practices in ambulatory care showed that patient-based interventions, particularly the use of delayed prescriptions for infections, for which antibiotics were not immediately indicated, effectively reduced antibiotic use by patients and did not result in excess morbidity.⁵

A systematic review of five trials (four based in the UK and one in New Zealand) undertaken by Arroll et al looked at whether delayed prescriptions actually reduced antibiotic use in RTIs. There was a consistent reduction in antibiotic usage in the five trials included in the review, suggesting that the delayed prescription is an effective means of reducing antibiotic usage for acute respiratory infections.⁶

But are patients satisfied with delayed prescriptions? A study in the BJGP in 2003, looked at patients’ responses to delayed prescriptions for acute upper RTIs. Just over half of the responders (53.1%) claimed to have consumed their antibiotics, while 87.1% were confident about taking the decision as to whether to use their antibiotics and 92.5% would choose to receive a delayed prescription again.⁷

One Irish study looking at the use of delayed prescriptions for non-specific URTI, sore throat and cough showed that 64% (29/45) of patients got the antibiotics from the pharmacy, of these patients, 55% (16/29) consumed the antibiotics while 45% (13/29) did not use the antibiotics but got them from the pharmacy. Patient confidence in deciding whether or not to use the antibiotics was high.⁸

A US study in JAMA in 2006 showed that in acute otitis media, delayed prescriptions reduce parents’ use of antibiotics from 87% to 38%. In addition, the parents who managed without antibiotics were more likely to say they would do without the next time (63% v 28%, P < 0.001).⁹

Delayed prescribing of topical antibiotics is probably the best strategy for managing acute conjunctivitis in primary care, say Everitt and colleagues.¹⁰ It reduced antibiotic use, showed no evidence of medicalisation, provided similar duration and severity of symptoms to immediate prescribing and reduced re-attendance for eye infections. 

With regard to our study as stated earlier, there was strong agreement among GPs that antibiotics are overused. The majority of GPs surveyed felt under pressure to prescribe antibiotics – some as often as every day.  

The majority of responding GPs (40%) felt that delaying prescriptions was a safe prescribing strategy; however, a large proportion (30%) remained neutral, indicating they may have had concerns. Overall, GPs felt that delayed prescriptions had the potential to cut down on antibiotic use (51% agreed and 31% strongly agreed).  

Delayed prescribing was also seen as a way of involving the patient in the management of their illness, with 53% of GPs surveyed agreeing and 30% strongly agreeing with this idea. The concept of patients finding delayed prescriptions confusing was rejected by the majority of GPs surveyed (45%).

With regard to the usage of delayed prescriptions, the majority of GPs surveyed (39.8%) use them once a week, 33% use them once a day, 12.6% use them once a month, 9.7% use them less than once per month or never and the minority 4.9% use them several times a day in their practice. Therefore, the delayed prescription for antibiotics continues to be a useful management option for the majority of GPs surveyed.  

Conclusion 

This study provides information about the use of delayed prescriptions in routine general practice in the mid-west. Delayed prescribing of antibiotics has been shown in several studies to be a safe method of prescribing in various diagnoses, including acute otitis media, sore throat, cough and acute conjunctivitis in both adults and children.^3,4,5,6,9,10

As long as patients have clear and specific information about when to use antibiotics and when to return for assessment, delayed prescribing of antibiotics for URTI is probably as safe or safer than other strategies and is acceptable to patients.¹¹

References

1. Tan T, Little P, Stokes T. Antibiotic prescribing for self-limiting respiratory tract infections in primary care: Summary of NICE guidance. BMJ 2008; 337: a437
2. Little P. Delayed Prescribing of antibiotics for upper respiratory tract infection. With clear guidance to patients and parents it seems to be safe.  BMJ 2005; 331(7512): 301-302
3. Little P, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL. Open randomised trial of prescribing strategies in managing sore throat. BMJ 1997; 314: 722
4. Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997; 315: 350-352
5. Spurling G, Del Mar C, Dooley L, Foxlee R. Delayed antibiotics for symptoms and complications of respiratory infections. Cochrane Database 2004; 18(4): CD 004417
6. Arroll B, Kenealy T, Kerse N. Do delayed prescriptions reduce antibiotic use in respiratory tract infections? A systematic review.  Br J Gen Pract. 2003; 53(496): 871-877
7. Edwards M, Dennison J, Sedgwick P. Patients’ responses to delayed antibiotic prescription for acute upper respiratory tract infections. Br J Gen Pract. 2003; 53(496): 845-850
8. Fitzpatrick S. The pros and cons of delayed prescriptions. Forum 2007; 24(8): 21
9. Spiro DM et al. Wait-and-see Prescription for the Treatment of Acute Otitis Media: A Randomized Controlled Trial. JAMA 2006; 296: 1235-41
10. Everitt HA, Little P, Smith PWF. A randomised controlled trial of management strategies for acute infective conjunctivitis in general practice.  BMJ 2006; 333:321
11. Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N. Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. BMJ 1998; 317: 637-642