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GPs should refuse rather than delay antibiotics for coughs and colds, Cochrane review concludes

GPs should say ‘no’ to patients who request antibiotics for minor respiratory infections rather than use the NICE-recommended practice of delayed prescribing, a gold standard review has suggested.

The systematic review by the Cochrane Collaboration showed patient outcomes and satisfaction were just as good, and with no increased risk of complications, when they were refused an antibiotic, compared with those offered a delayed prescription.

Patients were also no more likely to go back to their GP, while antibiotic use was greater in the group offered a delayed prescription.

NICE recommends delayed antibiotic prescribing as an option for managing self-limiting respiratory tract infections and to help reduce use of antibiotics. But leading GPs said the new Cochrane review shows this approach does not offer any advantages over offering no antibiotics at all.

Recent research has suggested offering delayed prescriptions for antibiotics had less effect in practice on antibiotic usage than first thought, and the Government’s Chief Medical Officer has signalled a further crackdown on antibiotic prescribing rates, even going as far as suggesting point-of-care diagnostic testing to guide antibiotic use in primary care.

To evaluate the likely impact of delayed prescribing, researchers analysed 10 studies, including a total of 3,157 patients with an acute respiratory tract infection, which compared delayed antibiotics with immediate antibiotics or no antibiotics at all.

For patients with coughs and common colds, there was no difference in terms of the severity and duration of pain, malaise, fever, cough and rhinorrhoea whether delayed, immediate or no antibiotics were prescribed. Immediate antibiotics were more effective than delayed antibiotics for pain, fever and malaise among patients with acute otitis media or sore throat in some studies.

Antibiotic use was lowest when no antibiotic was initially prescribed, with 14% of patients ending up taking one after going back to the GP. In comparison, 32% of patients offered a delayed prescription and 93% of those given an immediate prescription used an antibiotic. Yet patients reported being just as satisfied with no initial antibiotic prescription as with delayed prescription, with both strategies achieving over 80% satisfaction.

Moreover, the authors reported that there was no difference in reconsultation rates with immediate and delayed antibiotics.

They concluded: ‘In patients with respiratory infections where clinicians feel it is safe not to prescribe antibiotics immediately, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use, while maintaining similar patient satisfaction and clinical outcomes to delayed antibiotics.’

Dr Martin Duerden, a part-time GP and expert clinical adviser to RCGP on prescribing, said the review showed that ‘saying “no” to antibiotics causes few problems with patient dissatisfaction, presumably if the reasons are carefully articulated’.

He added: ‘I find GPs are often uncomfortable with delayed antibiotics as a strategy, as it seems a bit of a cop out if antibiotics are unlikely to improve outcomes. It may allow avoidance of confrontation and “give power” to the patient, but maybe it is not strictly honest and does not challenge the widely held public perception that antibiotics are necessary for conditions which are largely self-limiting.’

‘In an ideal world, patients should have ready access to the doctor or nurse if their symptoms get significantly worse or are not resolving in the expected time, either by phone or by re-consultation. Over 50% of antibiotics used in the UK for humans are prescribed by GPs for respiratory infections and there is a great variation in antibiotic prescribing between GPs, with little difference in outcome, suggesting much may be unnecessary.’  

Professor Paul Little, GP and professor of primary care at University of Southampton, noted that the reconsultation rate in the first month in one of the studies showed reduced reconsultations with delayed prescription.

‘So probably delayed prescription reduces reconsultations, and the difference in antibiotic use is not too different when the reconsultations are taken account of.’

He added: ‘However, I don’t think there is that much in it - so I think the clinician should do what they feel comfortable with. If using delayed prescribing the message needs to be clear with very clear messages about symptomatic treatment, the natural history of the illness and when to use antibiotics.’

Dr Michael Moore, GP and RCGP clinical champion for antibiotic stewardship, said: ‘I think that the main message from this review is that both the delayed and no antibiotic prescribing strategy have similar recovery rates and patient satisfaction rates but that both strategies substantially reduce antibiotic uptake.’

But Dr Moore said both delayed and no prescriptions were acceptable approaches, depending on the situation.

He explained: ‘In practice I tend to tailor the approach to the patient. So after making a clinical assessment I will explain that there is no evidence of serious infection needing antibiotics and that antibiotics are unlikely to confer much benefit in this particular illness.’

‘I find that about half will take the offer of a delayed prescription. It is always important to emphasise how long to wait and what symptoms would prompt use of the prescription. The delay is also tailored to the illness and the prior duration of symptoms. Some doctors used to prescribing may struggle with not offering a prescription so using a delayed prescription is a useful “halfway house” and would still substantially reduce antibiotic use.’

He added that the studies may not have been sufficiently powered to rule out any differences in serious complications among the strategies.

‘Certainly observational data supports there being a small increase in risk when less prescribing goes on but this needs to be balanced against the harms both from reactions to the antibiotics and in the longer term through increased bacterial resistance which as we know is potentially very serious indeed,’ Dr Moore said.

Cochrane Database of Systematic Reviews 2013: Issue 4: CD004417

Readers' comments (11)

  • 14percent of patients still managed to use antibiotic even though not prescribed?

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  • No point telling me;tell the patients and the likes of the Daily Wail

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  • Well thats all clarified then.......

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  • if some comes with three weeks cough with sputum. telling them one day your cough will go does not please patients. how long do you wait. they go elsewhere and get it. it would interesting to ask those patients who were refused how they felt and what did they do.

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  • I do like the way that they've not discussed the preferred treatment regimen for someone with chronic lung Dz. Is it then okay to tell them to go away and their cough will clear on its own? I think that this should have also been discussed because something as simple as a productive cough in a pt with chronic lung Dz should be given ABx to prevent this from turning into something more serious such as pneumonia!

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  • TELL NICE TO GET REAL. It is time that you grasp an insight into what happens with a cantacarous patient, with whom despite 15-20 mts of explanation will go into the circumloculatory consultation mode. UNTIL ABSOLUTE criteria are published and NICE and the like make it a NATIONAL POLICY/with PROTOCOL, AND GMP changes its wording, the practice of delayed script has worked very well in my experience with most patients, but NOT all. I am sure any sensible GP will do the same. TIme and again we have had patients at both extremes of age, presenting with "benign" symptoms of Infection, who either rapidly (In hours) have got worse and died. I am sure some GPs would have had complaints on this issue.

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  • Legally indemify us and we'll do it..ahh but you're not gonna do that are its water off a ducks back my friend.

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  • @Anonymous, 8.08 am - the 14% figure is for antibiotics prescribed to patients who were not initially prescribed one but were then offered one at reconsultation. Have updated the paragraph to try to make that clearer.

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  • National Hopeless Service

    There needs to be guidelines on how to give guidelines. Because I have no idea who is correct.

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  • This is where, we as a good GP should be able to contribute. I noticed patients that's known me for a while will trust my judgement and will be happy with my advice. They usually don't abuse the delayed script. On the other hand, those that's not developed a long term doctor-patient relationship often are demanding and distrusting. This is, of course not helped by daily mail and Jeremy Hunt's smear campaign.

    So I tend not to give delayed script for those that I think will ignore the advice. Instead I'll promise to see them again if they become unwell. Surely, that's common sense?

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  • I think it's going to be down to clinical judgement again and depending on the patient/parent. If I have said I think it's a viral illness where antibiotics are of no benefit but given a delayed prescription such as a Friday surgery with a child with history of om with pink drums but not red in case the otalgia gets worse and they are up all night- a scenario where probably most of my colleagues might do the same. I know some patients go straight to the chemist! ( would they if there was a charge I wonder? ) I do frequently not give however if the likelihood of serious deterioration is low. Also I accept there is an argument for never giving antibiotics in OM ! Personally I can reflect on the research, use the statistics in educating myself and patients and do what I feel is appropriate in each case. I'm sure others will do the same, guidelines are for guidance after all.

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