Back-up Antibiotic Prescriptions for Common Respiratory Symptoms

A large body of literature has addressed the frequent use of antibiotics for common upper and lower respiratory tract infections in the outpatient setting. The many dangers of this practice, including the development of bacterial resistance,^1,2 adverse drug reactions,^3-5 and negative financial implications,⁶ have been discussed, but very few methods to resolve the problem have been tested. Guidelines and educational strategies have been touted by some advocates as an essential part of the solution process and have been shown to have some degree of success in specific settings.^7,8 Recently, the American Academy of Family Physicians, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention have collaborated to develop a set of recommendations to help clinicians use antibiotics more appropriately when treating patients with common respiratory illnesses.^9-13 The results of these educational efforts have not been evaluated.

Although many aspects of the antibiotic overprescribing issue may start with physician beliefs, training, and practice setting, other factors have been postulated, including meeting patient expectations, economic issues, and time constraints. A practice that has not been reported in the literature but has been employed by many physicians (anecdotally) is the use of a back-up prescription strategy. This approach addresses the complex problem of satisfying patients in a timely manner while re-educating them in a nonconfrontational way.

The term “back-up prescription” applies to the writing of a prescription that is to be filled at a later time, and only if the patient’s condition deteriorates or fails to improve. At the time the prescription is written the physician explains to the patient (or the family) the reasons for not giving an immediate-fill antibiotic prescription and gives advice on symptomatic treatment for the current problem. Additionally, specific guidance is given on clinical parameters and the timing of when to fill the prescription if the condition progresses. To our knowledge, this practice has not been studied adequately in family medicine settings although similar strategies have been used for other health-related conditions.^14-16 The use of back-up treatment for malaria (also referred to as reserve treatment) has been mentioned in the literature.¹⁵ Davy and colleagues¹⁶ have also reported the use of back-up antibiotics for the treatment of undifferentiated acute respiratory tract infection with cough among primary care family physicians and pediatricians. This study, which was based on a self-reported survey, primarily sought to identify the frequency with which reserve antibiotics were prescribed to this group of children. It did not address the actual practice of using a back-up prescription.

In exploring the use of the back-up antibiotic prescription strategy it is essential to assess the degree of patient satisfaction and the fill rates for back-up prescriptions and their predictors. In their study on patient satisfaction and antibiotic prescriptions for respiratory infections, Hamm and coworkers¹⁷ elicited patient satisfaction levels immediately following a physician encounter. However, seeking the opinions of patients about their satisfaction immediately after an encounter may not yield accurate responses because more time may be required to assess other factors such as the effect (or lack of effect) of the treatment suggested, including antibiotic prescriptions given.

Methods

Study Design and Setting