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April 16, 2020

Delayed Antibiotic Prescriptions in Ambulatory Care: Reconsidering a Problematic Practice

Author Affiliations
  • 1Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
JAMA. 2020;323(18):1779-1780. doi:10.1001/jama.2020.2325

Delayed or backup antibiotic prescriptions are given to ambulatory patients with the expectation that the patient will pick up or fill the prescription if he or she is not improving within a few days. A 2017 Cochrane Collaboration systematic review found that delayed antibiotic prescriptions were associated with significantly decreased antibiotic use.1 Delayed antibiotic prescriptions are now included in ambulatory antibiotic stewardship recommendations.2,3 However, the strategy of delayed antibiotic prescribing is likely flawed, does not improve patient outcomes, and unnecessarily exposes patients to harm.

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    2 Comments for this article
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    Idealism vs Pragmatism
    Mark Ebell, MD, MS | University of Georgia
    I certainly respect the argument that Drs. Linder and Rowe make. In an ideal world, physicians would not prescribe unnecessary antibiotics. But, despite many years of effort, 70% of patients with acute bronchitis and almost everyone with acute sinusitis receives an immediate prescription for an antibiotic in the US, often a broad spectrum antibiotic. Delayed antibiotics may feel a bit unscientific, but the science is clear: they reduce the number filled antibiotic prescriptions more than any other intervention I'm aware of, including education and feedback. And, over time, they may educate patients that they don't need an antibiotic for every sniffle when they recover without having filled that prescription.

    Best,

    Mark Ebell MD, MS
    Professor, University of Georgia
    CONFLICT OF INTEREST: None Reported
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    Antibiotic Misprescribing Dilemma
    Jerry Garich, Pharm.D., MS | Community Clinic
    After nearly 50 years of the same performance with the same disastrous results from antibiotic prescribing (ie resistance) it appears we still have no workaround for bad prescribing. Since healthcare has mostly become what the insurance payers will authorize it's amazing to me that, in this age of exotic data-driven systems, third party payers still pay for antibiotics that don't match the appropriate diagnostic codes (ICD10). If they didn't and they penalized prescribers who were big offenders I wonder how fast we'd learn to get the antibiotic prescribing right. I'm confronted every day with providers who treat ARTIs or uncomplicated UTIsusing antibiotics that don't conform to IDSA, CDC, ACP or other guidelines and are resistant to change! So much for the team concept. Go figure.
    CONFLICT OF INTEREST: None Reported
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