• Mariam de la Poza Abad, Mas Dalmau Gemma G Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau, Barcelona, Spain., Mikel Moreno Bakedano, Ana Isabel González González, Yolanda Canellas Criado, Silvia Hernández Anadón, Rafael Rotaeche del Campo, Pere Torán Monserrat, Antonio Negrete Palma, Laura Muñoz Ortiz, Eulàlia Borrell Thió, Carl Llor, Paul Little, Pablo Alonso-Coello, and Delayed Antibiotic Prescription (DAP) Group.
• Doctor Carles Ribas Primary Care Center, Barcelona, Spain.
• JAMA Intern Med. 2016 Jan 1; 176 (1): 21-9.

ImportanceDelayed antibiotic prescription helps to reduce antibiotic use with reasonable symptom control. There are different strategies of delayed prescription, but it is not yet clear which one is the most effective.ObjectiveTo determine the efficacy and safety of 2 delayed strategies in acute, uncomplicated respiratory infections.Design, Setting, And ParticipantsWe recruited 405 adults with acute, uncomplicated respiratory infections from 23 primary care centers in Spain to participate in a pragmatic, open-label, randomized clinical trial.InterventionsPatients were randomized to 1 of 4 potential prescription strategies: (1) a delayed patient-led prescription strategy; (2) a delayed prescription collection strategy requiring patients to collect their prescription from the primary care center; (3) an immediate prescription strategy; or (4) a no antibiotic strategy. Delayed prescription strategies consist of prescribing an antibiotic to take only if the symptoms worsen or if there is no improvement several days after the medical visit.Main Outcomes And MeasuresThe primary outcomes were the duration of symptoms and severity of symptoms. Each symptom was scored using a 6-point Likert scale (scores of 3 or 4 were considered moderate; 5 or 6, severe). Secondary outcomes included antibiotic use, patient satisfaction, and patients' beliefs in the effectiveness of antibiotics.ResultsA total of 405 patients were recruited, 398 of whom were included in the analysis; 136 patients (34.2%) were men; mean (SD) age, 45 (17) years. The mean severity of symptoms ranged from 1.8 to 3.5 points on the Likert scale, and mean (SD) duration of symptoms described on first visit was 6 (6) days. The mean (SD) general health status on first visit was 54 (20) based on a scale with 0 indicating worst health status; 100, best status. Overall, 314 patients (80.1%) were nonsmokers, and 372 patients (93.5%) did not have a respiratory comorbidity. The presence of symptoms on first visit was similar among the 4 groups. The mean (SD) duration of severe symptoms was 3.6 (3.3) days for the immediate prescription group and 4.7 (3.6) days for the no prescription group. The median (interquartile range [IQR]) of severe symptoms was 3 (1-4) days for the prescription collection group and 3 (2-6) days for the patient-led prescription group. The median (IQR) of the maximum severity for any symptom was 5 (3-5) for the immediate prescription group and the prescription collection group; 5 (4-5) for the patient-led prescription group; and 5 (4-6) for the no prescription group. Patients randomized 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 across groups.Conclusions And RelevanceDelayed strategies were associated with slightly greater but clinically similar symptom burden and duration and also with substantially reduced antibiotic use when compared with an immediate strategy.Trial Registrationclinicaltrials.gov Identifier: NCT01363531.

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