Clinical Question

In patients with respiratory tract infections (bronchitis, sinusitis, pharyngitis), is a delayed prescription strategy as effective as immediate treatment and as accepted by patients?

Bottom Line

In almost 400 Spanish primary care patients with mild to moderate symptoms of respiratory infection of less than one week's duration, both a “take-and-hold” prescription and a “come back and pick up, if necessary” prescription produced a similar clinical response—and similar patient satisfaction score—as immediate antibiotic treatment, while decreasing overall antibiotic use. Other studies of this patient population have shown that patients prefer the security of a prescription, delayed or not, over withholding antibiotic treatment. The effect of legitimizing an illness by awarding a prescription should not be underestimated. (Level of Evidence = 1b)

Synopsis

These researchers evaluated 398 adults with acute, uncomplicated respiratory infections from 23 primary care centers in Spain. The patients had acute pharyngitis (46%), acute bronchitis (32%), rhinosinusitis (20%), or exacerbation of mild to moderate chronic obstructive pulmonary disease (2%). The physicians had “reasonable doubt as to whether to treat with an antibiotic.” Patients were, on average, on the younger side (mid-40s), one-half were smokers or former smokers, almost no patients (less than 2%) were febrile, and they reported mild to moderate symptoms for an average of six days. Patients were randomized, using concealed allocation, to one of four potential prescription strategies. One group was given an antibiotic to begin at once; two groups were given a delayed prescription, either a “take and hold” prescription or a “come back and pick up, if necessary” prescription; and the final group was not given any prescription. The average duration of symptoms was significantly longer in patients not given a prescription compared with patients given an immediate antibiotic, with the duration of symptoms in patients given delayed prescriptions somewhere in between but not significantly different from the immediate prescription. The duration of moderate or severe symptoms was lessened significantly with immediate treatment compared with delayed prescriptions, but the average difference in duration was 0.5 to 1.0 day. Patients in the delayed prescription groups experienced fewer days absent from work or unable to do their daily activities. Patient satisfaction was similar across all groups. Prescription use was decreased by two-thirds with the delayed prescription approaches.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (primary care)

Reference: de la Poza AbadMMas DalmauGMoreno BakedanoMet alDelayed Antibiotic Prescription (DAP) GroupPrescription strategies in acute uncomplicated respiratory infections: a randomized clinical trial. JAMA Intern Med2016; 176( 1): 21– 29.