NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

Do I really need to prescribe an immediate antibiotic for lower respiratory tract infections?

A recent large observational UK general practice study of 28,883 patients with uncomplicated lower respiratory tract infection (RTI) (BMJ 2017;357:j2148) supports other evidence that there is little to be gained from prescribing immediate antibiotics. The two main findings were:

Hospital admission or death following consultation for lower RTI was extremely rare and was not reduced by prescribing antibiotics immediately (0.3% no antibiotics; 0.4% delayed; 0.9% immediate).

Re-consultations were common (14.1% patients returning for non-resolving; 25.3% worsening; 19.7% new symptoms) BUT were significatly reduced with a delayed prescribing strategy (multivariable risk ratio 0.64, 0.57 to 0.72, P<0.001).

How do I use delayed prescribing in practice?

Studies have shown that it doesn't matter how you do delayed prescribing (i.e. give prescription with advice, ask to re-contact or collect prescription at a later date) as long as it is used in the correct circumstances and patients are provided with the correct information. Information that can help includes following the 6Rs consultation framework below, and also using the TARGET 'Treating Your Infection' leaflet. This leaflet highlights the natural duration of self-limiting RTI (during which time antibiotics are unlikely to be required), and provides safety netting advice. It also includes the option to write an appropriate delay period (based on how long they have already had symptoms for) so the patient knows when would be reasonable to take action (e.g. phone advice, appointment, prescription) if they have not started to get better.

Discuss the 6Rs in your consultation:

1. Reassurance

2. Reasons not to give antibiotic

3. Relief: paracetamol

4. Realistic natural duration (at least 3 weeks for cough)

5. Reinforce key message: ONLY use if getting worse and not STARTING to settle in expected natural time

6. Rescue (safety netting)

ScRAP 2: 'Targetting prescribing for RTI' learning session can support you and your colleagues to reflect on prescribing for self-limiting RTI and reduce unnecessary prescribing.


Published 28/07/2017