When an individual develops a respiratory infection, antibiotics are often prescribed, despite the fact that many are caused by viruses that are not susceptible to the antibiotic. A new study by Spanish researchers has reported that not rushing to antibiotic use can be the best choice. The findings were published online on December 21 in the journal JAMA Internal Medicine.
The study authors note that a respiratory infection is one of the most common reasons for a visit to a family physician; the most frequent types of infections are rhinitis (nasal inflammation), pharyngitis (sore throat), and acute bronchitis (inflammation of lung passages). Most respiratory infections are self-limiting, and recent studies have suggested that antibiotics have a minimal impact on the course of the infection. However, in the US, approximately 60% of patients with a sore throat and 71% of patients with acute uncomplicated bronchitis are still prescribed an antibiotic. They caution that overprescription of antibiotics not only increases resistance to these drugs but also strains resources, places patients at risk of adverse effects, and increases the number of future doctor visits for similar episodes. In primary care, the availability of diagnostic procedures (e.g., chest X-ray and cultures) is usually limited; thus, contributing to diagnostic uncertainty and promoting the prescription of an antibiotic even when there is no clear evidence of a bacterial infection. In addition, antibiotics are often prescribed because doctors and patients are concerned regarding the risk of complications and because many patients still expect an antibiotic prescription. Furthermore, this expectation that may be overestimated by physicians.
The use of delayed prescription varies widely among nations and no evidence is available for the United States. Therefore, the authors designed our study to determine the effectiveness of two delayed antibiotic strategies compared to immediate antibiotic prescription or no antibiotic prescription. For the study, the researchers recruited 405 adults with acute, uncomplicated respiratory infections from 23 primary care centers in Spain to participate in a randomized clinical trial.
The patients were randomly assigned to one of four prescription strategies: (1) a delayed patient-led prescription strategy; (2) a delayed prescription collection strategy requiring patients to pick up their prescription from the primary care center; (3) an immediate prescription strategy; or (4) a no antibiotic strategy. Delayed prescription strategies consisted of prescribing an antibiotic to take only if the symptoms increased or if there was no improvement several days after the medical visit.
The symptoms were scored with a 6-point Likert scale (3-4: moderate; 5 -6). In addition, antibiotic use, patient satisfaction, and patients’ beliefs in the effectiveness of antibiotics was assessed. A total of 405 patients were recruited, and 398 were included in the analysis; 136 patients (34.2%) were men with an average age of 45 years. The average severity of symptoms ranged from 1.8 to 3.5 points on the Likert scale, and the average duration of symptoms described on first visit was six days. The average general health status on first visit was 54 (based on a scale with 0 indicating worst health status and 100 indicating best status. Overall, 314 patients (80.1%) were nonsmokers, and 372 patients (93.5%) did not have any coexisting respiratory problems such as emphysema or asthma. The presence of symptoms on first visit was similar among the four groups. Patients randomly assigned to the no prescription strategy or to either of the delayed strategies used fewer antibiotics and less frequently believed in antibiotic effectiveness. Satisfaction was similar among the four groups.
The authors concluded that delayed strategies were associated with slightly greater but clinically similar symptom burden and duration. However, they were also associated with substantially reduced antibiotic use when compared to an immediate strategy.