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What matters: delayed prescribing of antibiotics.

While not a new phenomenon, antimicrobial resistance is an alarming and, arguably, still underappreciated public health problem. A mere 70 years after the introduction of antibiotics, we face the distinct possibility of a future without effective antibiotics for some infections. Such a reality will render select surgical operations, cancer chemotherapy, and organ transplants exceedingly dangerous.

Caption: DR. EBBERT

The scarcity of new antimicrobial agents an the paucity of new agents in the drug development pipeline limit treatment options, particularly for patients with infections caused by multidrug-resistant organisms. Annually, multidrug resistant organisms cause an estimated 25,000 deaths in Europe and 12,000 deaths in the United States. In response to this threat, the Transadantic Taskforce on Antimicrobial Resistance (TATFAR) was established and published their report with 17 recommendations.

Respiratory tract infections are one of the most common symptoms presenting to primary care. Overprescribing in this setting is rampant, driven largely by patient expectations and clinician need for expediency and desire to receive "high marks" for satisfaction. Available evidence has suggested that delayed antibiotic prescribing is effective. But what is the best method to delay antibiotic prescribing?

Researchers in the United Kingdom evaluated the comparative effectiveness of four different strategies of delayed antibiotic prescribing for patients not needing antibiotics right away:

* Recontact: Patients were asked to contact the office and leave a message for a clinician to prescribe an antibiotic.

* Postdated prescription: The prescription could be filled only after a certain date.

* Wait/request: Patients were instructed to wait but could request an antibiotic from the front office.

* Delayed use: Patients received antibiotics but were asked to wait to use them.

A "no prescription" arm was added later in the trial. The primary outcome was symptom severity measured at the end of each day during days 2-4 of a 2-week symptom diary. Secondary outcomes included antibiotic use and side effects.

No differences were observed between the four strategies with respect to symptom control. Antibiotic use did not differ significantly between strategies and the lowest use was reported in the no-prescription arm. No significant differences were observed between groups in patient satisfaction. Complications were slightly higher in the no-antibiotic group (2.5%), compared with the delayed groups (1.4%).

Delayed prescribing is associated with less than 40% of patients using an antibiotic. Given the multidrug-resistance crisis, we should feel obligated to try one of the proposed strategies for delayed antibiotic prescription if patients do not need one right away.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. He reports no conflicts of interest. Scan the QR code to read What Matters on
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Title Annotation:OPINION
Author:Ebbert, Jon O.
Publication:Internal Medicine News
Date:Apr 15, 2014
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