Either a patient needs antibiotics or they don’t. If a patient needs antibiotics, a delayed prescription is harmful. If a patient doesn’t need antibiotics, a delayed prescription is harmful. Thus, delayed antibiotics are dumb.
That paragraph could have stood alone as my shortest (and perhaps best) blog post ever. However, the practice of providing patients with a prescription for delayed antibiotics has become so popular, I should probably expand on my thinking a little more. Like anything in medicine, there is likely some grey area to explore.
Proponents of delayed antibiotic prescriptions will point to a lot of evidence that they are associated with a decrease in antibiotic use. (Spurling 2017) Although they are technically correct, the decrease in antibiotics is compared to control groups that are practicing bad medicine. If doctors are giving 100% of patients with viral URTIs antibiotics, and the delayed prescription gets that rate down to 80%, that still means that 80% of patients are being harmed by bad care. I don’t think we should count that as a win, but that is exactly what is happening in this research. Depending on the study, as many as half of patients still end up filling their prescription. Of course, seeing as antibiotics don’t help viral infections, the clinical outcomes are exactly the same as giving no antibiotics at all. (Spurling 2017)
This practice is directly harmful, in that it unnecessarily exposes patients to the many harms of antibiotics. It also has probably results in many indirect harms. It is incredibly confusing to patients. We are simultaneously telling them that antibiotics are unnecessary for their condition and yet giving them a prescription for an antibiotic. How are those conflicting actions supposed to be interpreted?
The whole point of delayed antibiotic prescriptions is to decrease antibiotic use, but compared to simply not prescribing antibiotics, delayed prescriptions result in a dramatic increase in antibiotic use. (Spurling 2017) In other words, this strategy completely fails at the only objective it was designed to achieve. If you want to decrease antibiotic use, stop prescribing antibiotics when they are not necessary. Its that simple.
I think there might be a few reasonable exceptions to the black and white picture I have painted so far. However, I don’t think any of them are represented in the standard conversations about delayed antibiotics. Viral URTIs don’t need antibiotics. Otitis media doesn’t need antibiotics. Whether you give them now or later, you are probably causing your patient harm.
However, there are a number of conditions that do require antibiotics, but that aren’t always clinically obvious. Sometimes a patient comes in with hot, red, swollen skin that you are pretty sure is just a local reaction to a bug bite, but it could be cellulitis. The ideal answer is probably treating the bug bite and having the patient reassessed, but realistically, even in a country where there isn’t a direct cost to see a doctor, follow up appointments are inconvenient, and there are many indirect costs that arise from that repeat visit. Therefore, I will occasionally give a prescription for cephalexin to be started in 2-3 days if the lesion doesn’t improve with time, ice, and antihistamines. However, this scenario is drastically different from the scenarios in which delayed antibiotics are typically employed, because I am actually treating a bacterial illness for which antibiotics are the appropriate therapy. Antibiotics are not appropriate for a viral pharyngitis, no matter how long you wait.
It is true that some patients want antibiotics and are more satisfied with their visit when they receive their prescription. However, when a patient has misunderstandings about medicine, the appropriate approach is to educate and guide them, not try to trick them with a delayed prescription.
Realistically, the delayed antibiotic concept was probably more about trying to change doctors than patients. Antibiotics over-prescription is a doctor problem, not a patient problem. We are the ones writing the prescriptions. We are the ones failing to teach our patients.
Behavioral scientists may disagree with my rant. They may point out that doctors are stubborn and stuck in their ways; that doctors are unlikely to stop writing unnecessary prescriptions, but we might be able to convince them to write a different date. If you want to admit that you are this stubborn, fine, but it doesn’t change the fact that delayed antibiotics don’t make any sense.
I will close with a quote from the excellent editorial that prompted this rant: “Ultimately, delayed antibiotic prescriptions expose patients to unnecessary and potentially harmful medications and do not improve clinical outcomes… Health care professionals have a responsibility to do what is in the best interest of patients even if there are concerns that doing so will make some patients unhappy or unsatisfied. For patients with viral conditions, that responsibility means not prescribing immediate or delayed antibiotics.” (Rowe 2020)
Rowe TA, Linder JA. Delayed Antibiotic Prescriptions in Ambulatory Care: Reconsidering a Problematic Practice. JAMA. 2020;10.1001/jama.2020.2325. doi:10.1001/jama.2020.2325 PMID: 32297898
Spurling GK, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotic prescriptions for respiratory infections. Cochrane Database Syst Rev. 2017;9(9):CD004417. Published 2017 Sep 7. doi:10.1002/14651858.CD004417.pub5 PMID: 28881007