BACKGROUND: Antibiotics are generally ineffective for patients with acute cough,1 yet they continue to be prescribed frequently by primary care physicians. A recent observational study showed that delayed prescribing can reduce antibiotic use for such patients without leading to patient dissatisfaction, but symptom outcomes were not reported.2
POPULATION STUDIED: This study enrolled 191 patients older than 16 years who presented to 1 of 22 Scottish general practices with a primary complaint of acute cough with or without coryza, shortness of breath, sputum, fever, sore throat, or chest tightness. The researchers excluded 2 groups: patients expressing a strong preference for antibiotics or for whom the general practitioner (GP) would not have considered antibiotics.
STUDY DESIGN AND VALIDITY: This was an unblinded randomized controlled trial. The patients were assigned to 1 of 2 groups; the immediate group received an antibiotic prescription at the visit, and the delayed group had their prescription held at the reception desk for 2 weeks and were invited to pick it up at any time, if required. Outcomes were measured by patient questionnaires (78% return rate), physician questionnaires (98% return rate), and a chart review (88% of charts). The strengths of this study were a proper randomization procedure, adequate allocation concealment, an intention-to-treat analysis, and baseline similarity between groups in terms of symptoms and belief in antibiotics. Weaknesses included an unblinded study design and possible selection bias in both physician and patient recruitment (a minority of eligible practices participated, and the GPs taking part enrolled between 1 and 25 patients each). The study only recruited half the target number of patients, so the power to detect clinical differences between groups was less than anticipated.
OUTCOMES MEASURED: The number and timing of collected prescriptions in the delayed group were recorded. The patient questionnaire included daily presence of cough and other symptoms, satisfaction with the visit, and the patient’s intention of consulting for future similar illnesses. The physician questionnaire asked for impressions of the utility of and frequency with which patients subsequently used delayed prescribing. Chart reviews noted the number of return visits for similar illnesses in the subsequent 6 or more months.
RESULTS: Almost half (45%) of the patients in the delayed group picked up their prescriptions after an average of 6 days and were more likely to do so if they had persistent symptoms or were more worried about their cough. Beginning with day 4 following the visit, there was a nonstatistically significant trend in the persistence of cough between groups that widened on day 7 (75% in the delayed group still coughing compared with 55% in the immediate group) and narrowed on day 10. By day 14, a similar number of patients were still coughing (35% in the delayed group vs 30% in the immediate group). The authors state there were no differences in other symptoms (data not provided). Fewer patients in the delayed group were very satisfied with the visit (54% vs 73%; P=.03; number needed to harm [NNH]=5), and more were dissatisfied with the treatment (13% vs 0%; P=.001; NNH=8). Patients of the GPs who recruited fewer patients were more likely to be very satisfied than those of GPs who recruited more patients. Chart reviews did not reveal a difference in return visits between groups. Eighty-seven percent of the physicians described delayed prescription as a useful strategy, and 68% used this method at least monthly.
Compared with immediate prescribing, delayed prescribing reduces antibiotic use in patients with acute cough. The downside is that some patients may be less satisfied or have a few more days of cough with this strategy, but eventual clinical outcomes and return rates are similar.
For this strategy to effectively decrease unnecessary antibiotic use, however, physicians should only use it for patients for whom they might consider antibiotics and not for all patients who present with clearly viral respiratory tract infections.