Strategies Used to Avoid Antibiotic Prescription in Patients With Acute Respiratory Tract Infections May Not Result in Substantially Increased Antibiotic Use Compared to Not Prescribing Antibiotics at Initial Clinic Visit

EBM Focus - Volume 9, Issue 1

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Reference: BMJ 2014 Mar 6;348:g1606 (level 2 [mid-level] evidence)

Acute respiratory infections are commonly encountered in primary care, and symptom control is often the chief concern of patients. The American College of Physicians recommends against using antibiotics to treat nonspecific upper respiratory tract infections in previously healthy adults (Ann Intern Med. 2001 Mar 20;134(6):487), and a recent Cochrane review found that antibiotics do not reduce symptoms of the common cold or acute purulent rhinitis (Cochrane Database Syst Rev 2013 Jun 4;(6):CD000247). However, patient expectations for treating respiratory infections with antibiotics have helped fuel their use in primary care, even though they are not recommended and our best available evidence suggests they are ineffective for these conditions. A variety of methods for delaying use of antibiotics until symptoms resolve on their own have been proposed. A recent randomized trial evaluated several of these methods in patients with acute respiratory infection who were judged not to require antibiotic treatment.

A total of 889 patients aged 3 years or older with acute respiratory tract infection were assessed and followed for at least 1 month. Respiratory infections included acute cold, influenza, sore throat, otitis media, sinusitis, croup, or lower respiratory tract infection. After initial evaluation, 333 patients were judged to require antibiotics and immediately prescribed antibiotics for their use. The remaining 556 patients were judged not to need antibiotics, and were randomized to 1 of 5 strategies for avoiding antibiotics: requiring patients to recontact the clinic by phone to request a prescription (recontact), postdating the prescription (postdate), allowing patients to collect prescription from the clinic themselves (collection), giving patients a prescription but asking them to wait before use (patient led), and simply not prescribing antibiotics at all (no prescription).

The rate of antibiotic use was 26% among those not prescribed antibiotics, but the manner in which patients obtained antibiotics without initially having them prescribed was not addressed in the study. There were no significant differences in antibiotic use between any of the strategies to avoid antibiotics and the strategy of no prescription, but the confidence intervals for the observed differences cannot rule out clinically significant effects. The rates of antibiotic use were 37% with the recontact strategy, 37% with the postdate strategy, 33% with the collection strategy, and 39% with the patient-led strategy. There were no significant differences in comparisons of any groups to the no prescription group in mean symptom severity scores on days 2-4 or median duration of symptoms rated moderately bad or worse.

The use of antibiotics in common conditions like acute respiratory infection has been an important driver for the development of antibiotic resistance, and over time this may severely limit treatment options for serious infectious diseases. This randomized trial shows that several strategies for avoiding antibiotics can reduce their use by patients without any significant differences in symptom scores on days 2-4, when respiratory symptoms are typically at their worst. Any decrease in antibiotic use may help reduce growing rates of antibiotic resistance in the community. These findings reinforce current treatment guidelines and existing clinical evidence, and also support several different strategies to help reduce unnecessary antibiotic use in primary care. These data also reinforce messages about antibiotic prescribing for respiratory infections promoted by the Choosing Wisely initiative, which provides evidence-based recommendations for patients and healthcare professionals that can act as a basis for shared decision making in clinical practice. The Get Smart program from the Centers for Disease Control and Prevention provides similar information, along with a variety of patient-focused print materials.

For more information see the Upper respiratory infection (URI) topic in DynaMed.

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