Discussing antibiotics with patients

C Concerns:

Ask specifically about patient’s concerns, do not solely rely on patient history. If concerns are not specifically asked about, the patient will sometimes not share their main worries for fear of being seen as ‘overly-anxious’.

There are probably a number of things that are worrying you about this illness, but what would you say are the things that you are most worried about?’

‘You’ve mentioned the high temperature; is that the thing that is causing you most worry at the moment, or is it something else?’

‘When you feel like this it can be pretty worrying, and I just want to make sure that I have a clear understanding of what you are most worried about at the moment. Is it the cough that is worrying you most? Or perhaps there is something else worrying you?’

H History & exam:

Discuss history & exam to help reassure patients that they are being listened to. While doing an examination provide a running commentary for example

“no problem”

“Your heart rate is normal, your temperature isn’t raised, your lungs sound good.”

E Expectations:

The only way of actually knowing what patients want or expect is to ask them. A 2021 survey of the general public found an increase in those expecting antibiotics from the GP compared to the previous year, however there was also an increase in those wanting information on whether or not they actually needed the expected antibiotic. A patient that appears ‘demanding’ may actually just want reassurance that the infection has not ‘gone down to the chest’, rather than antibiotics.

Consider asking the patient about the expectations

“How do you think I could most help you today?”

“How do you feel about antibiotics?”

S Symptoms:

Provide non-serious explanation for symptoms.

“Your body produces phlegm as a normal reaction to inflammation in the airways to your lungs.’”

“The phlegm catches particles in your airways and helps keep your lungs clear.”

T Timeline:

Be specific about illness timeline / usual course. A typical duration of common infections can be: Sore throat: 7-8 days | Sinusitis: 14-21 days | Cough or bronchitis: 21 days | Otitis media: 8 days | Common cold: 14 days

“A typical cough can take 3-4 weeks to clear completely.”

S Shortcomings:

Explain shortcomings of antibiotics:

‘Research shows that on average antibiotics may help reduce how long your cough lasts by only 1 day in an illness lasting 3–4 weeks.’

‘Antibiotics don’t help with pain but have side effects, such as diarrhoea, nausea and rash, which can be experienced by up to 1 in 10 people taking antibiotics.’

S Self-Care:

Advise patients how to self-care:

‘The immune system needs normal fluids to work properly, it is working hard to fight off the infection, so you need to make sure you are drinking enough – when people are unwell they often drink less without noticing.’

‘Pain in the chest or throat is normally due to inflammation, you can take paracetamol, and/or ibuprofen, which will help the pain and soothe the inflammation.’

See the TARGET leaflet section for more information on discussing safety-netting with patients.

S Safety-Netting:

Provide safety-netting advice, Provide patients with specific information on red-flag symptoms and when they should seek further help.

See the TARGET leaflet section for more information on discussing safety-netting with patients.

Patients are likely to better understand and accept a back-up/delayed antibiotic prescription if you discuss two key points:

1. Reasons for giving it

It can be helpful to:

• provide reassurance that there is no need for an immediate antibiotic prescription and, if given, the patient is more likely to experience the side effects of antibiotics rather than the benefits;
• although the illness is likely to be self-limiting, acknowledge that it is not possible to predict exactly how the illness will progress;
• and that you would like the patient to have access to antibiotics should their symptoms get worse or not improve as expected.

2. Specific number of days to wait

For example: "wait another 2 days and start the antibiotic if you are not feeling any better by then".

• It is important to be specific as your patient may worry about waiting too long if they are not confident about when to start the antibiotics.
• Your advice should be tailored to the patient’s current experience of the infection, the prior duration and expected natural history, their co-morbidities, and their ability to access antibiotics in a timely manner. The TARGET patient information leaflets can help with this.

These can be incorporated in the last four techniques in CHESTSSS (Timeline, Shortcomings, Self-care, Safety-netting).

What some prescribers might say	How some patients might interpret this	Alternative suggestion
“It’s probably a virus so an antibiotic won't help…here’s a back-up prescription just in case your symptoms get worse.”	"If it’s a virus how will an antibiotic help later?"	“At the moment there are no signs of a serious infection. Your body is fighting the infection and that’s usually enough for you to recover. Most [infection type] usually last X days so the symptoms will most likely go away on their own and you should be feeling better by X day. If you don’t feel better by X day, then you can use the back-up prescription."
“You don’t need an antibiotic now but if your symptoms don’t improve within X days, then you can use the back-up prescription.”	"Why not start the antibiotic now?  What’s the benefit to me to delay?"	"Your immune system should be able to clear this [infection] without antibiotics. Antibiotics do not usually make the symptoms go away much quicker for this type of infection and you might get side effects, such as diarrhoea and nausea, so it would be better to let your body’s own immune system manage this infection. If your symptoms get worse [give specific examples] over the next X days, then you can use the back-up antibiotic." (See ‘safety-netting advice' and 'shortcomings of antibiotics’ CHESTSSS).

The format you use to give a back-up/delayed antibiotic prescription to a patient makes little difference to antibiotic use - as long as you give clear advice to patients.

1. Give a prescription with advice to get it dispensed if needed
2. Ask the patient to collect prescription from an agreed location (e.g. the reception or pharmacy if using electronic prescription transfer)
3. Write a post-dated prescription
4. Ask the patient to contact the practice again to obtain a prescription
5. Ask the patient to collect the antibiotic now but only use it if needed

If you want to capture the use of back-up/delayed antibiotic prescriptions in your practice, then all prescribers should be encouraged to use the relevant READ/SNOMED codes for 'deferred' antibiotics.

READ codes (e.g., Emis, Vision)	SNOMED code (System One)	Definition
8BP0	2549788011	deferred antibiotic therapy
8CAk	406111000000113	patient advised to delay filling of prescription
8OAN	2462831000000113	provision of TARGET Managing Your Common Infection (Self-Care) Leaflet with back-up antibiotic prescription issued

Or start typing ‘deferred antibiotic’ and the code should appear

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.