As all practicing clinicians know, patients often expect antibiotics when they come in with typical URI, sinusitis, otitis, or bronchitis symptoms. Clinicians understandably feel caught between a rock and a hard place. To accede to the antibiotic expectation helps patient satisfaction and may lead to a shorter visit, but as we all know, it also can worsen the problem of antibiotic resistance. To not prescribe antibiotics risks lower patient satisfaction and often leads to a longer visit, since the patient needs to be educated about why antibiotics are not being given. Especially when patients firmly avow, “I always need antibiotics when I get this infection.”
We all know the right course to follow is the second one. A recent study published in the March 5, 2014, BMJ provides more evidence that avoiding antibiotic prescriptions for typical URIs is safe. Researchers looked at 889 patients ages 3 and over who presented to their primary care clinician with the usual URI symptoms. A little more than one-third were prescribed immediate antibiotics. These patients tended to be somewhat sicker. For the remaining patients, they were randomized to either delayed antibiotics or no antibiotics. Several delayed-antibiotic methodologies were used, including giving patients a post-dated or non-post-dated prescription to use if the symptoms were not improving after a specified interval, or leaving a prescription at the reception window which the patient could drop by to pick up on their own if they were not getting better.
Eventually, one-quarter of those not given an antibiotic prescription initially ended up using antibiotics. For those randomized to one of the delayed-antibiotic use regimens, one-third ended up using antibiotics. Notably, symptom scores were not significantly different among all groups. There were minor differences in office visit utilization, but there were no significant clinical complications in any of the groups.
What this study shows is that delaying antibiotics in patients presenting with URI symptoms can be done safely. Patients’ symptoms are not influenced by antibiotics. When negotiating with a patient who is adamant about needing antibiotics, adopting a delayed-antibiotic approach may help. Such an approach can reduce antibiotic use and help wean patients away from their belief system that antibiotics are necessary to fight URIs. Ultimately, educating our patients about why we are reluctant to hand out antibiotics when they are not needed will yield benefits down the road.
Richard Fleming, MD