Discussing antibiotics 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
8OAN	967191000000104	Provision of Treating Your Infection self-care patient leaflet with back-up antibiotic prescription issued (procedure)
8CAk	248041000000103	Patient advised to delay filling of prescription (situation)
8BP0	417576009	Deferred antibiotic therapy (situation)
n/a	1065591000000109	Delayed prescription given (situation)

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