Resistance to antibiotics is an important public health concern; with a recent substantial increase in the burden of antibiotic resistance, resistance to second- and third-line antibiotics is predicted to increase by 70% by 2030 if effective public health measures are not employed (Organisation for Economic Cooperation and Development, 2018). Therefore, such effective measures are sought and implemented where possible where evidence supports the use of the measure, to protect future public health. The pandemic has made the world very aware of the consequences of a viral infection that people could not be protected against until the vaccine was developed, and the results could be similar for a wave of everyday microbial infections that also can no longer be treated due to resistance to antimicrobial treatment.
One of the main measures that can be undertaken to tackle this looming crisis is to reduce unnecessary and inappropriate use of antibiotics where possible, particularly so in primary care, where antibiotics are most prescribed.
In 2016, the National Institute for Health and Care Excellence (NICE) released a quality statement declaring that prescribers in primary care could use delayed prescribing of antimicrobials where they were uncertain about whether a condition is self-limiting or likely to deteriorate. The rationale for this was that, when there is clinical uncertainty regarding such a presentation of a patient, delayed prescribing offers health professionals an alternative to the immediate prescription of antibiotics, which may do more harm than good if the patient were to then become resistant following several more prescriptions in similar circumstances, as is so often the case for older, frail or disabled people in the community with chronic conditions that involve frequent symptoms of possible infection.
This idea encourages then self-management as the first step, but it would also allow a person to access antibiotics without another appointment if their condition does go on to worsen. For GPs, health centres and pharmacies, this quality statement, therefore, meant that systems should be in place in these environments to allow delayed antimicrobial prescribing where there is uncertainty about how a condition will progress. For commissioners, this meant that clinical commissioning groups (CCGs) and NHS England would allow and monitor the practice in such circumstances of uncertainty over the patient's condition, and, for patients, it meant that they would be able to have a prescription for an antimicrobial with the agreement that they should only go on to use this if their condition worsens (NICE, 2016). This practice is also known as ‘back-up prescribing’, and the patient should always be given clear instructions about when they should use the prescription.
Of course, the downside may be that the patient does not follow the instructions and, either through inability to understand how to judge their symptoms or through anxiety-led actions, seeks the antimicrobials earlier than required and takes them anyway. In other cases, some patients who do deteriorate may have delayed taking the antibiotic for too long until they are too unwell to be able to access the drugs, and the many patients who live alone with chronic conditions and perhaps some level of cognitive decline may be at risk of this. Therefore, practitioners should always exercise caution when applying the practice of delayed prescribing.
In a recent systematic review, Stuart et al (2021) noted that antimicrobials continue to be over-prescribed across the country and on a global scale, which has a huge potential impact on the burden to come when resistance to such treatments is at an all-time high. Therefore, delayed prescribing appears to be the way forward—a useful compromise to reassure both the patient and prescriber.
With delayed antimicrobial prescribing, patients can also contribute to reducing the burden of antimicrobial resistance
Stuart et al (2021) found that delayed antibiotics result in longer duration of symptoms than immediate antibiotics, but are as effective for the remaining clinical outcomes. Consistent results were collected in subgroups that would normally be observed to be at higher risk, suggesting that delayed prescribing is unlikely to lead to poorer symptom control than immediate antibiotics (Stuart et al, 2021).
A strength of this research is that it is a large study and had the ability to control for baseline severity, to assess the quality of the studies based on the full dataset, to explore heterogeneity across studies and to include results obtained from randomised controlled trials (RCTs) and observational studies (Stuart et al, 2021). As with many studies, selection bias associated with trials can hinder perceived external validity. Therefore, a strength of this research was the ability to include observational data, which improves external validity. However, further studies are required for low-to middle-income countries in order to evaluate whether delayed antibiotic prescribing would be a safe and effective strategy in such settings. Another limitation is that not all outcomes were collected in all studies. Symptom severity data were not collected for all of the studies, or they had only been collected for a subset of participants in some studies, which resulted in a smaller sample size for the outcome analysis. Additionally, this outcome was based on diary data, which may not represent all study participants and could, therefore, also impact generalisability.
The researchers have stated that, despite this, previously published estimates from included studies have suggested that those who did complete the diaries had broadly similar characteristics to all recruited participants (Stuart et al, 2021). Overall, it appears that delayed antimicrobial prescribing is a safe and effective strategy with minimal risk that may help to tackle the looming antimicrobial resistance crisis that, perhaps, will be the next big topic to address on the world health agenda following the pandemic.