antibiotics for URI

BMJ online just published an article showing utility of delaying antibiotics, or giving no antibiotics, in patients with upper resp infection (link: http://www.bmj.com/content/348/bmj.g1606.pdf%2Bhtml ). in brief,

    --889 pts over age 3 (median age 30) in 25 practices in UK were given advice about symptom control (antipyretics, +/- vaporizer) and then either immediate antibiotics in 333 (37%) (the group felt to have more severe sx and felt more likely to have lower resp tract infection), and in 556 (63%) randomized to the following different strategies:
            --having the patient subsequently recontact the clinic to request a prescription if needed -- pts told that symptoms typically worst on days 2-4
            --post-dating the prescription
            --having the patient come back to the clinic just for a prescription if needed
            --given a prescription but asking the patient to wait to fill it
            --no antibiotic prescribed
    --results
            --mean symptom severity at 3-4 days no diff between getting no prescription vs any of the delayed methods. 
            --no diff in duration of sx rated moderately bad or worse (median 3-4 days), whether in the immediate script, delayed script, or no script groups
            --nonsignif difference in patient satisfaction in the different groups, belief in antibiotics, or antibiotic use, though no benefit in symptom severity or duration of symptoms. no diff in patient revisits to the clinic.
            --with the no prescription or delayed prescription policies, the median day that antibiotics were started was day 4, and <40% of patients actually took antibiotics (approx 25% of the no prescription group ultimately got antibiotics)

the background here is that, per the NICE guidelines (natl institute for health and care excellence in the UK), it is suggested to give an antibiotic prescription advising the patient to wait for at least the expected natural history of the illness (the study found that delayed scripts only have a slightly higher fill rate than giving no antibiotics). the advantage of the delayed script over none is that the former decreases the likelihood of patients coming back for another visit. also didn't seem to matter which method used for delayed scripts. and, in this study, only a minority of patients actually filled the prescriptions, even if they were given them with the advice to wait a few days to see how they were.  also, of note, no difference in disease response in the group given immediate antibiotics vs those in delayed or no antibiotics (not an RCT, however). my experience is that, at least in our clinic and perhaps through reiteration over the years of the lack of utility of antibiotics, most patients are happy to be reassured that "it is just a virus" and not insist on getting antibiotics. and, perhaps in some patients, it is a good idea to see them in a few days if they are not getting better/getting worse. 

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