title: Prescription Strategies in Acute Uncomplicated Respiratory Infections: A Randomized Clinical Trial.
abstract: OBJECTIVE
  Delayed 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.
  
  
  OBJECTIVE
  To determine the efficacy and safety of 2 delayed strategies in acute, uncomplicated respiratory infections.
  
  
  METHODS
  We 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.
  
  
  METHODS
  Patients 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.
  
  
  METHODS
  The 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.
  
  
  RESULTS
  A 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
  Delayed 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.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01363531.
authors.affiliation: Doctor Carles Ribas Primary Care Center, Barcelona, Spain.
authors.forename: Mariam
authors.initials: M
authors.lastname: de la Poza Abad
authors.affiliation: Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau, Barcelona, Spain.
authors.forename: Gemma
authors.initials: G
authors.lastname: Mas Dalmau
authors.affiliation: Irurtzun Primary Care Center, Irurtzun, Spain.
authors.forename: Mikel
authors.initials: M
authors.lastname: Moreno Bakedano
authors.affiliation: Vicente Muzas Primary Care Center, Madrid, Spain5Red de investigación en Servicios de Salud en Enfermedades Crónicas, Spain6Evidence-Based Medicine Group, SemFYC, Spain.
authors.forename: Ana Isabel
authors.initials: AI
authors.lastname: González González
authors.affiliation: Monovar Primary Care Center, Madrid, Spain.
authors.forename: Yolanda
authors.initials: Y
authors.lastname: Canellas Criado
authors.affiliation: Jaume I Primary Care Center, Tarragona, Spain.
authors.forename: Silvia
authors.initials: S
authors.lastname: Hernández Anadón
authors.affiliation: Evidence-Based Medicine Group, SemFYC, Spain9Alza Osakidetza Primary Care Center, Kronikgune Group about Knowledge Management, Basque Health Service, Spain.
authors.forename: Rafael
authors.initials: R
authors.lastname: Rotaeche del Campo
authors.affiliation: Research Support Unit Metropolitana Nord, Jordi Gol University Institute for Research Primary Healthcare, Santa Coloma de Gramenet, Spain11El Maresme Primary Care Center, Mataró, Spain.
authors.forename: Pere
authors.initials: P
authors.lastname: Torán Monserrat
authors.affiliation: El Maresme Primary Care Center, Mataró, Spain.
authors.forename: Antonio
authors.initials: A
authors.lastname: Negrete Palma
authors.affiliation: Research Support Unit Metropolitana Nord, Jordi Gol University Institute for Research Primary Healthcare, Santa Coloma de Gramenet, Spain.
authors.forename: Laura
authors.initials: L
authors.lastname: Muñoz Ortiz
authors.affiliation: Sant Roc Primary Care Center, Badalona, Spain.
authors.forename: Eulàlia
authors.initials: E
authors.lastname: Borrell Thió
authors.affiliation: Via Roma Primary Care Center, Barcelona, Spain.
authors.forename: Carl
authors.initials: C
authors.lastname: Llor
authors.affiliation: Aldermoor Primary Care Center, Aldermoor Close, Southampton, United Kingdom.
authors.forename: Paul
authors.initials: P
authors.lastname: Little
authors.affiliation: Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau, Barcelona, Spain6Evidence-Based Medicine Group, SemFYC, Spain15CIBER de Epidemiología y Salud Pública, Spain.
authors.forename: Pablo
authors.initials: P
authors.lastname: Alonso-Coello
mesh_terms: D000208:Acute Disease; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001991:Bronchitis / Q000188:drug therapy*; D005260:Female; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D010612:Pharyngitis / Q000188:drug therapy*; D012141:Respiratory Tract Infections / Q000188:drug therapy*; D012220:Rhinitis / Q000188:drug therapy*; D012852:Sinusitis / Q000188:drug therapy*; D061665:Time-to-Treatment; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents