Are Sore Throat Patients Who Hope for Antibiotics Actually Asking for Pain Relief?

Indeed, several studies show that the strategy of 'delayed prescriptions' reduces antibiotic use. But, I always feel uneasy with this strategy. We tell our patients that they don't need antibiotics and at the same time we give them a prescription. As if we're not sure about it. Also, when they don't get better (or get worse), I'd prefer to see them rather than have them pick up a prescription from the pharmacy. It's not easy to break old habits (both for doctors who prescribe antibiotics and for patients who want them). But, if we continue giving the same message, it must be possible to change. We have some indirect evidence from a comparative study of 2 populations living only a few miles apart in The Netherlands and Belgium.(1) Deschepper et al found that people in The Netherlands prefer to label upper respiratory tract symptoms as "a cold" or "a flu" and do not consider antibiotics useful. But for the same condition Belgians speak of "bronchitis" that is associated with a need for antibiotics. In The Netherlands antibiotic prescribing rates have been low compared to Belgium for many years, so patients may have been educated by these restrictive prescribing habits of their physicians. In our study we also included some family physicians from The Netherlands. They had a hard time finding patients with an uncomplicated acute sore throat. Patients know what to do in the acute phase and only consult their doctor when they feel it doesn't get well or gets worse. I guess the main message is that we need to be convinced that it's OK not to prescribe antibiotics and need to educate our patients. It'll take a while, but we must try if we don't want antibiotic resistance to catch up with us.

1. Deschepper R, Vander Stichele RH, Haaijer-Ruskamp FM. Cross- cultural differences in lay attitudes and utilisation of antibiotics in a Belgian and a Dutch city. Patient Educ Couns 2002;48:161-9.

Competing interests:   None declared

Yes, it is difficult to resist the direct request. A number of investigators have found the "delayed prescription" approach to be quite effective. Only 30 to 50% of patients fill a prescription if they are told "you probably don't need this; your body will fight off the infection just as quick. but here is a presciption to fill in a couple of days just in case."

John

Competing interests:   None declared

Your patients sound very familiar. We found that our patients who hope for antibiotics were significantly more concerned about pain. They might think that antibiotics are the best way to deal with their pain and not prescribing antibiotics could be interpreted as “the doctor wants me to suffer”. Of course, that makes them unhappy. If you want your patients to leave your office satisfied, you could consider using another approach. In stead of (wasting your time) explaining why they don’t need antibiotics, you could explore what they worry about and address these specific concerns. Then you would really have something to offer. Other researchers have also shown that patients aren’t necessarily unsatisfied if they don’t get the antibiotics they initially wanted. They rather value information and being taken seriously. (1) Also, do not underestimate the educational effect of your prescribing practice: the most important predictor of wanting antibiotics is a prescription for antibiotics in the past.(2) Prescribing antibiotics for patients who don’t need them doesn’t save time (3,4), doesn’t address their needs, exposes them to unnecessary side effects, and is far from “good clinical practice”. It may be as simple as just listening, reassuring and alleviating pain. Why not try?

1. Butler CC, Rollnick S, Kinnersley P, Jones A, Stott N. Reducing antibiotics for respiratory tract symptoms In primary care: consolidating ‘why’ and considering ‘how’. Br J Gen Pract 1998;48:1865-70.

2. Mainous A, Zoorob R, Oler M, Haynes D. Patient knowledge of upper respiratory infections: implications for antibiotic expectations and unnecessary utilization. J Fam Pract 1997;45(75-83.

3. Coco A, Mainous AG. Relation of time spent in an encounter with the use of antibiotics in pediatric office visits for viral respiratory infections. Arch Pediatr Adolesc Med 2005;159:1145-1149.

4. Linder JA, Singer DE, Stafford RS. Association between antibiotic prescribing and visit duration in adults with upper respiratory tract infections. Clin Ther 2003;25:2419-30.

Competing interests:   None declared