delayed or back up antibiotic prescription in sore throat

Last edited 07/2018 and last reviewed 06/2021

• a systematic review was undertaken to evaluate the prescribing strategy of delayed antibiotics for acute respiratory tract infections compared to immediate or no antibiotics for clinical outcomes, antibiotic use and patient satisfaction
• study data:
  • nine trials were eligible on the basis of design and relevant outcomes
    • for most clinical outcomes there was no difference between delayed, immediate and no antibiotics
      • antibiotics prescribed immediately were more effective than delayed for fever, pain and malaise in some studies of patients with acute otitis media and sore throat but for other studies there was no difference
• study authors concluded that, for most clinical outcomes there is no difference between the strategies
  • immediate antibiotics was the strategy most likely to provide the best clinical outcomes in patients with sore throat and otitis media
  • delaying or avoiding antibiotics, rather than providing them immediately, reduces antibiotic use for acute respiratory infections
  • delay also reduced patient satisfaction in three trials, compared to immediate antibiotics with no difference in two other trials
  • delaying antibiotics seems to have little advantage over avoiding them altogether where it is safe to do so

NICE have given guidance regarding use of delayed prescription of antibiotics (back-up prescription) for sore throat:

• people who may be more likely to benefit from an antibiotic (FeverPAIN score of 2 or 3)

  • consider no antibiotic prescription with advice or a back-up antibiotic prescription (delayed prescription), taking account of:
    • evidence that antibiotics make little difference to how long symptoms last (on average, they shorten symptoms by about 16 hours)
    • evidence that most people feel better after 1 week, with or without antibiotics
    • the unlikely event of complications if antibiotics are withheld
    • possible adverse effects, particularly diarrhoea and nausea
      
      
• people who are most likely to benefit from an antibiotic (FeverPAIN score of 4 or 5, or Centor score of 3 or 4)

• consider an immediate antibiotic prescription, or a back-up antibiotic prescription, taking account of:
  • the unlikely event of complications if antibiotics are withheld
  • possible adverse effects, particularly diarrhoea and nausea.
  • when an immediate antibiotic prescription is given, as well as the general advice (see notes), give advice about seeking medical help if symptoms worsen rapidly or significantly or the person becomes systemically very unwell
    
    
• back-up prescription
  • a back-up (delayed) prescription is one that is given in a way to delay the use of a medicine (usually an antibiotic), and with advice to only use it if symptoms worsen or don't improve within a specified time. The prescription may be given during the consultation (which may be a post-dated prescription) or left at an agreed location for collection at a later date
  • when a back-up antibiotic prescription is given, as well as the general advice, give advice about:
    • an antibiotic not being needed immediately
    • using the back-up prescription if symptoms do not start to improve within 3 to 5 days or if they worsen rapidly or significantly at any time
    • seeking medical help if symptoms worsen rapidly or significantly or the person becomes systemically very unwell.

Reference:

• (1) Spurling GK et al. Delayed antibiotics for respiratory infections.Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004417
• (2) NICE (January 2018).Sore throat (acute): antimicrobial prescribing