Delayed (or ‘back-up’) antibiotic prescription, where the patient is given a prescription but advised to
delay initiating antibiotics, has been shown to be effective in reducing antibiotic use in primary care.
However, this strategy is not widely used in the UK. This study aimed to identify factors influencing
preferences among the UK public for delayed prescription, and understand their relative importance,
to help increase appropriate use of this prescribing option.
Methods and Findings
We conducted an online choice experiment in two UK general population samples: adults, and parents
of children under 18 years. Respondents were presented with twelve scenarios in which they, or their
child, might need antibiotics for a respiratory tract infection, and asked to choose either an immediate
or a delayed prescription. Scenarios were described by seven attributes. Data were collected between
November 2018 and February 2019. Respondent preferences were modelled using mixed-effects
logistic regression.
The survey was completed by 802 adults and 801 parents (75% of those who opened the survey). The
samples reflected the UK population in age, sex, ethnicity and country of residence. The most
important determinant of respondent choice was symptom severity, especially for cough-related
symptoms. In the adult sample the probability of choosing delayed prescription was 0.53 (95% CI 0.50-
0.56, p<.001) for a chesty cough and runny nose, compared to 0.30 (0.28-0.33, p<.001) for a chesty
cough with fever, 0.47 (0.44-0.50, p<.001) for sore throat with swollen glands and 0.37 (0.34-0.39,
p<.001) for sore throat, swollen glands and fever. Respondents were less likely to choose delayed
prescription with increasing duration of illness (odds ratio 0.94 (0.92-0.96, p<0.001)). Probabilities of
choosing delayed prescription were similar for parents considering treatment for a child (44% of
choices vs. 42% for adults, p=0.04). However, parents differed from the adult sample in showing a
more marked reduction in choice of the delayed prescription with increasing duration of illness (OR
0.83 (0.80-0.87) vs 0.94 (0.92-0.96) for adults, p for heterogeneity <0.001), and a smaller effect of
disruption of usual activities (OR 0.96 (0.95-0.97) vs. 0.93 (0.92-0.94) for adults, p for heterogeneity
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<0.001). Females were more likely to choose a delayed prescription than males for minor symptoms,
particularly minor cough (probability 0.62 (0.58-0.66, p<0.001) for females, 0.45 (0.41-0.48, p<0.001)
for males). Older people, those with a good understanding of antibiotics, and those who had not used
antibiotics recently, showed similar patterns of preferences. Study limitations include its hypothetical
nature, which may not reflect real-life behaviour; the absence of a “no prescription” option; and the
possibility that study respondents may not represent the views of population groups who are typically
under-represented in on-line surveys.
Conclusion
This study found that delayed prescription appears to be an acceptable approach to reducing
antibiotic consumption. Certain groups appear to be more amenable to delayed prescription,
suggesting particular opportunities for increased use of this strategy. Prescribing choices for sore
throat may need additional explanation to ensure patient acceptance, and parents in particular may
benefit from reassurance about the usual duration of these illnesses