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Delayed Prescribing: A Clinical Antimicrobial Stewardship Strategy

Delayed prescribing is an evidence-based antimicrobial stewardship (AMS) strategy for reducing unnecessary antibiotic use in general practice, while providing an acceptable compromise between immediate and no antibiotic prescribing.¹ To be effective, delayed prescribing should be delivered within the context of ‘safety netting’, including discussion of diagnostic uncertainty, the expected duration of the illness [natural history], clear instructions on when to start antibiotics, and advice on when further reassessment is needed.¹  

Patients are more likely to feel comfortable with a delayed antibiotic prescription when GPs clearly explain why it has been provided and when it should be used. Reassure patients that antibiotics are not needed at this time because they are unlikely to provide significant benefit and may cause side effects and explain that the infection will likely improve on its own, though it is difficult to predict exactly how it will progress.  

Advice about when to commence antibiotics should be specific and individualised. Patients may be concerned about delaying treatment if they are unsure of the signs that antibiotics are needed. Guidance should therefore be tailored to the patient’s current symptoms, illness duration, expected recovery trajectory, comorbidities, and ability to promptly access antibiotics if required. Advice on symptomatic management should also be offered alongside delayed prescribing. 

Safety of Delayed Prescribing  

A large UK cohort study examined outcomes following consultations for respiratory tract infections.² 

 

The study found no difference in serious adverse outcomes between immediate prescribing, delayed prescribing, and no prescribing. In addition, serious outcomes such as hospital admission or death occurred in less than 1% of cases, and patients given delayed prescriptions were less likely to reconsult with new, worsening or non-resolving symptoms compared with no prescribing, suggesting reassurance and improved self-management.

Giving a Delayed Script

The way you provide a delayed antibiotic prescription makes little difference if patients are given clear instructions. This could be accompanied by a patient information sheet including information on recommended symptomatic treatments. 

 

Procedures to provide the delayed script could be ¹’³ :  

  • Providing the delayed prescription as either a paper prescription or an electronic prescription (eScript), depending on your usual practice workflow, along with clear instructions in which circumstances it should be filled – including time without improvement (typically 48 or 72 hours). This is the most commonly-used procedure.  
  • Ask the patient to contact the practice if symptoms do not improve by a certain time (typically 48 or 72 hours) or become worse, so a prescription, if appropriate, will be available to be picked up from the practice reception desk. 

References

  1. Magin P, Davey AR, Davis J. Evidence-based strategies for better antibiotic prescribing. Aust J Gen Pract. 2022 Jan-Feb;51(1-2):21-24.  
  2. Little P, Stuart B, Smith S, Thompson MJ, Knox K, van den Bruel A, Lown M, Moore M, Mant D. Antibiotic prescription strategies and adverse outcome for uncomplicated lower respiratory tract infections: prospective cough complication cohort (3C) study. BMJ. 2017 May 22;357:j2148. 
  3. Sargent L, McCullough A, Del Mar C, Lowe J. Is Australia ready to implement delayed prescribing in primary care? A review of the evidence. Aust Fam Physician. 2016 Sep;45(9):688-90.