How to do it… The 6 R’s

Next very important question is how to do it and related questions. So it’s actually pretty easy. It’s not rocket science, but it does need to be done properly. And if you do it properly, it will then reduce antibiotic use. So I’ve called them the 6 R’s but, you know, it’s slightly artificial. Most of those 6 R’s are simply good practice in the NICE guidance. So the first thing is reassurance that they don’t need antibiotics immediately because they’re not likely to get anything horrible happening to them.

The second thing is reasons not to use antibiotics. So antibiotics have side effects, allergy, and the side effect if you have a like of anti-microbial resistance. The third thing is providing good advice about symptom relief– the third R. And I would advise regular paracetamol in the maximal doses. And in that context, I would say please don’t use non-steroidals or very limited use of nonsteroidals. I won’t talk about that in great detail, but we showed in one of our trials that if you give nonsteroidals like ibuprofen, you get longer duration, more severe illness, and people are more likely to come back with either progression of symptoms or complications. So I would just stick with paracetamol. So simple advice about paracetamol.

And this fourth R which is incredibly important if you’re doing a delayed prescription. Give people a realistic idea of their natural history. Not only did lots of doctors not know what the average natural history is, but patients certainly don’t. And I would use my rule of thumb, to be honest, half a week, a week, two weeks, or three weeks depending on the particular respiratory infection. The fifth R is reinforce the key message that you only want people to use the delayed prescription if they’re getting worse or not even starting to settle in the expected average time that you’ve just talked about.

And then finally, you need to give some information about if nasty things start happening, they need to come back and see you as a safety netting. OK, so that’s the first bit– the 6 R’s of how to do it. The second bit of how to do it is that you can give a delayed prescription in any number of ways. So you can say come back and see me, or give me a phone call and I can give a prescription. You can postdate the prescription. So for a sore throat you’d say I’d give you a postdated prescription for five days. That’s a little bit more constraining.

You can ask them to come and collect it which is probably what we’ve done in most of our studies. And you have to be a little bit flexible about that. So if you want them to collect it and that would, on average, turn out to be a Sunday, then you have to be flexible about the kind of advice you give. Or lastly, you can just give it and say very clear advice about when to take it, as I’ve just described in the previous slide. So if you do those four things, does it make any difference? Well, that’s what we did in the PIPS trial published in the BMJ.

And so as you can see, those four types of delayed prescribing– recontacting, postdating, collecting, or patient end, you just give it– we looked at, and we compared it to both to no prescriptions and also to an immediate antibiotic prescription. Actually, that isn’t shown, but results very similar in terms of the symptom severity. Really no significant difference in symptom severity there. Similar duration of illness. In terms of belief in antibiotics, really, you are doing pretty well with delayed prescription. Quite interesting, though, that even if you don’t give an antibiotic, lots of people will still believe in an antibiotic. What happens if you give an antibiotic is that 99% of people believe that it’s helpful.

So you’re reducing the number who believe each time you don’t prescribe. In terms of antibiotic use, yes, sure a no prescription will give you the lowest antibiotic use, and about 10% more people will use an antibiotic prescription if you’ve done a delayed prescription properly as described. And people are pretty satisfied with no prescription. I mean, of these various ones, the ones that we’ve trialled the most in all of our trials is asking people to pop back and collect it. People are pretty satisfied, pretty low antibiotic use, and lower beliefs in antibiotics. So that’s the one that I would probably concentrate on. But I would be flexible. If you do it properly, it doesn’t really matter which of these you do.

You will get similarish results, OK?

So overall, considering that the data on symptom control and antibiotic use are delayed or a backup prescription, it certainly effective in reducing antibiotic use. If it’s done properly, it changes beliefs and behaviour, and overall symptom control is pretty good.