Discussing antibiotics with patients
Why use this approach to discuss antibiotics?
Effective prescriber–patient communication is an integral part of the consultation process facilitating shared decision making, patient empowerment and satisfaction with care, whilst building a meaningful and trusting relationship.
Although there may be patient expectation for antibiotics and this may drive unnecessary antibiotic prescription, a 2021 survey of the general public found that the majority of the respondents trust their health care provider advice, and found an increase in those wanting information on whether or not they actually needed antibiotics
How can using this approach help you?
Prescribers already have good general communication skills and have their own individual approaches. However, given short consultations, it is easy to miss out an important element of a consultation. This can have a big impact on whether your patients are happy with a prescribing decision.
Tweaking your discussions with patients can help:
- Increase patient satisfaction: Patients report high levels of satisfaction and enablement in managing their infection, and are more informed about the appropriate use and harms of antibiotics when you discuss antibiotics effectively and when they discuss leaflets interactively.
- Reduce consultations: Prudent antibiotic prescribing with effective discussions about antibiotics help reduce re-consultations and future consultations. So it is worth investing a bit of time in these consultations.
- Reduce your antibiotic prescribing: The examples of how you may tweak your discussions with patients presented in the ‘Discussing Antibiotics with Patients’ website section have been shown to be effective in reducing antibiotic prescribing when trialled with prescribers in UK general practice.
This approach and the examples provided focus on discussions with patients with acute infections but you may find them helpful for other consultations.
Evidence of benefits
Evidence shows that prescribers often overestimate patients' expectations for antibiotics and that patients' satisfaction is related to:
- Having a careful and thorough examination.
- Having their concerns identified and addressed.
- Having advice on how to manage their symptoms.
The examples and techniques presented in the ‘Discussing Antibiotics with Patients’ website section are based on enhanced communication skills training that has been shown to be effective in a trial with experienced GPs in the UK and on the STAR training also shown effective in a UK-based trial. The CHESTTS acronym was also developed and tested in this trial; however, it was modified to CHESTSSS afterwards, where the T was split into two Ss – shortcomings and self-care.
Evidence from a systematic review and a Cochrane overview of reviews also found support for the use of communication skills training and shared decision making as effective strategies to optimise antibiotic prescribing in primary care.
Common questions and concerns
Some prescribers may have questions and concerns about using this approach, for example:
"I already use communication skills so what do these resources add?"
Other prescribers have found it helpful to have examples of phrases to use and patients respond positively to these phrases. In particular, prescribers value the "timeline" examples, e.g. discussing and understanding how long infections normally last, and antibiotic "shortcomings", and "shortcomings", e.g. explaining that antibiotics will not shorten the duration by much or help with pain. Sometimes patients may misinterpret what prescribers say (e.g. telling a patient that they have a viral infection may not reassure them and may make them feel 'fobbed off') - so finding the right words is important.
"There isn't enough time in consultations."
The examples are short sentences that can be easily and quickly incorporated into what you already do in consultations.
"How will this help with 'challenging' patients?"
Going through the elements of effective consultations can be especially helpful with patients who are particularly concerned about their illness or expect/demand antibiotics. For example, providing non-serious explanations for symptoms, explaining how long infections normally last, explaining shortcomings of antibiotics and the benefits of back-up/delayed antibiotic prescriptions can help address patient concerns and reassure them.
My patients have limited English language skills."
TARGET patient leaflets are helpful in these situations and are available here in many different languages and pictorial format.
How can back-up/delayed prescriptions help you?
Back-up/delayed antibiotic prescriptions may be helpful (instead of an immediate antibiotic prescription) when:
- You are uncertain about how an infection might progress.
- The patient remains concerned about illness progression and is requesting antibiotics despite discussing antibiotics.
- You are concerned that the patient may need antibiotics when they will have limited access to medical care.
A 2021 general public survey showed that the public are increasingly more accepting of delaying prescriptions for UTIs and RTIs (manuscript in draft) and Trial evidence shows that when patients are given a back-up/delayed prescription only around one third start the antibiotics.
Evidence of benefits
Research evidence from UK-based studies (Little et al. 2014a, Little et al. 2014b, Little et al. 2017) and a Cochrane systematic review (Spurling et al. 2017) has shown that using back-up/delayed antibiotic prescriptions (instead of immediate antibiotic prescriptions) with a good explanation is a safe and effective strategy for managing common respiratory tract infections to:
- Reduce re-consultations more effectively than immediate antibiotic prescriptions, saving both patient and practice time.
- Prevent complications as effectively as immediate antibiotic prescriptions.
- Reduce antibiotic use as only 33% - 39% of patients use antibiotics when given a back-up/delayed prescription.
- Increase patients' ability to self-manage their infection (patients report no significant worsening in the duration of illness or experience of pain).
- Reduce future consultations for similar illnesses.
Common questions and concerns
Some prescribers may be concerned about increasing their use of back-up/delayed prescriptions and have questions:
"How long does it take to explain?"
Using the examples provided it takes less than a minute to explain a back-up/delayed prescription.
"Will this give a mixed message to patients about whether antibiotics are beneficial?"
Using the examples provided you can explain to patients that they are allowing time for their immune system to fight the infection and only using antibiotics if symptoms get worse or do not improve.
"Will patients know how long they should wait before starting antibiotics?"
It is most useful for patients if you can specify the number of days that they should wait before using the antibiotics, rather than saying "a few days".
"Will patients just take the antibiotics straight away?"
Research has shown that when a back-up/delayed prescription is explained well, patients use antibiotics approximately 30% of the time.
Providing a good explanation of a back-up/delayed antibiotic prescription to patients will help to address these concerns.
If you are certain that the patient does not need antibiotics, you can discuss antibiotics using the right words to provide a good explanation and reassurance on why antibiotics are not necessary.
You can remind patients to return any unused medicines to a pharmacy for safe disposal.
What do others say about using back-up/delayed antibiotic prescriptions?
Check out the two (2 minute) videos of Prof. Paul Little (GP & Professor of Primary Care) (in the webinar and training section) using the DESCARTE study to explain the benefits of back-up/delayed antibiotic prescriptions. These videos are from a free online course "TARGET Antibiotics - Prescribing in Primary Care" which you can sign up to here.