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Delayed strategies decrease antibiotic use in adults

Clinical Question:
Is a method of delayed prescriptions for respiratory tract infections effective for decreasing antibiotic use?

Bottom Line:
A delayed prescription approach in children and adults with acute respiratory tract infections, combined with explicit instructions for symptom control, is effective in decreasing antibiotic use, while not adversely affecting patient satisfaction or symptom duration or severity. Asking patients to call, pick up, or simply hold a prescription for a prescribed time resulted in less than 40% of patients receiving antibiotics. (LOE = 1b)

Little P, Moore M, Kelly J, et al, for the PIPS Investigators. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, randomised controlled trial. BMJ 2014;348:g1606.  [PMID:24603565]

Study Design:
Randomized controlled trial (nonblinded)



Outpatient (primary care)

Primary care clinicians in 25 practices in the United Kingdom participated in this study. They enrolled 566 children (at least 3 years of age) and adults with acute respiratory infection evaluated for respiratory tract symptoms deemed to not require antibiotic treatment (62.5% of eligible visits). The patients were randomly assigned, using concealed allocation, to 1 of 4 strategies: (1) no prescription, (2) recontact the office if symptoms persist, (3) a post-dated prescription was given, (4) a prescription was left at reception to be picked up if symptoms persisted, or (5) patients were given a prescription and asked not to fill it unless symptoms persisted. The advice for length of delay was tailored to the type of illness (eg, 3 days for ear infections, 10 days for acute cough). In addition, patients were also randomized to receive different advice for symptom control (type of analgesic or use of steam inhalation). Symptom severity on the second and fourth days following the visit were similar between the no prescription group and any of the delayed prescription groups, as well as between these groups and the patients immediately treated with antibiotics. Patient satisfaction with the visit was also similar among all groups. The actual percentage of patients in the no prescription or delayed prescription groups that eventually took antibiotics ranged from 26% to 39% (difference not significant). Follow-up visits and complications were similar across all groups.


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