Delayed prescribing has been promoted as a strategy that meets patients' expectations and helps to avoid unnecessary use of antibiotics in upper respiratory tract infections. To explore GPs' views on and experiences with delayed prescribing in patients with acute upper respiratory tract infections. Qualitative study involving focus groups. Setting Norwegian general practice. Qualitative analysis of data collected from five focus groups comprising 33 GPs who took part in a quality-improvement programme of antibiotic prescribing. The views of GPs differed on the usefulness of delayed prescribing. GPs who endorsed the strategy emphasised shared decision making and the creation of opportunities for educating patients, whereas GPs who were negative applied the strategy mainly when being pressed to prescribe. Mild and mainly harmless conditions of a possible bacterial origin, such as acute sinusitis and acute otitis, were considered most suitable for delayed prescribing. A key argument for issuing a wait-and-see prescription was that it helped patients avoid seeking after-hours care. For issuing a wait-and-see prescription, the GPs required that the patient was 'knowledgeable', able to understand the indications for antibiotics, and motivated for shared decision making. GPs emphasised that patients should be informed thoroughly when receiving a wait-and-see prescription. Not all GPs endorse delayed prescribing; however, it appears to be a feasible approach for managing patients with early symptoms of mild upper respiratory tract infections of a possible bacterial origin. Informing the patients properly while issuing wait-and-see prescriptions is essential.

Delayed prescribing of antibiotics for respiratory tract infections (RTIs) lowers the amount of antibiotics consumed. Several national treatment guidelines on RTIs recommend the strategy. When advocating treatment innovations, the feasibility and credibility of the innovation must be taken into account. The objective of this study was to explore GPs use and patients uptake of wait-and-see prescriptions for RTIs, and to investigate the feasibility of the strategy from GPs' and patients' perspectives.

The Prescription Peer Academic Detailing (Rx-PAD) project is an educational intervention study aiming at improving GPs' competence in pharmacotherapy. GPs in CME peer groups were randomised to receive a tailored intervention, either to support a safer prescription practice for elderly patients or to improve prescribing of antibiotics to patients with respiratory tract infections. The project was based on the principles of peer group academic detailing, incorporating individual feedback on GPs' prescription patterns. We did a study to explore GPs and tutors' experiences with peer group academic detailing, and to explore GPs' reasons for deviating from recommended prescribing practice.

Background: a suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Frequently, antibiotics are prescribed unnecessarily. To increase appropriate antibiotic use for UTIs through antibiotic stewardship interventions, we need to thoroughly understand the factors that contribute to these prescribing decisions. Objectives: (1) to obtain insight into factors contributing to antibiotic prescribing for suspected UTIs in frail older adults. (2) To develop an overarching model integrating these factors to guide the development of antibiotic stewardship interventions for UTIs in frail older adults. Methods: we conducted an exploratory qualitative study with 61 semi-structured interviews in older adult care settings in Poland, the Netherlands, Norway and Sweden. We interviewed physicians, nursing staff, patients and informal caregivers. Results: participants described a chain of decisions by patients, caregivers and/or nursing staff preceding the ultimate decision to prescribe antibiotics by the physician. We identified five themes of influence: (1) the clinical situation and its complexity within the frail older patient, (2) diagnostic factors, such as asymptomatic bacteriuria, (3) knowledge (gaps) and attitude, (4) communication: interprofessional, and with patients and relatives and (5) context and organisation of care, including factors such as availability of antibiotics (over the counter), antibiotic stewardship efforts and factors concerning out-of-hours care. Conclusions: decision-making on suspected UTIs in frail older adults is a complex, multifactorial process. Due to the diverse international setting and stakeholder variety, we were able to provide a comprehensive overview of factors to guide the development of antibiotic stewardship interventions.

Background Delayed antibiotic prescribing is an effective method of reducing the consumption of antibiotics for respiratory tract infections (RTIs). However, interventions to promote its use remain unexplored. Aim To measure the effects of a GP educational intervention and a computer delayed-prescribing pop-up reminder on antibiotic-dispensing rates. The study also aimed to identify factors influencing GPs’ decisions to issue delayed prescriptions and patients’ decisions to fill their prescriptions. Design and setting Controlled trial nested within a cluster-randomised controlled trial in urban and rural practices in 11 counties in southern Norway. Method Educational intervention and control groups were randomly populated from 81 continuing medical education groups. Within the intervention arm, 107 of the 156 participating GPs were assigned, based on the electronic patient-record system they used, to having a pop-up reminder installed on their computers. Data on prescribed and dispensed antibiotics from 1 year before, and 1 year during, the intervention were collected and linked. Results Valid data were obtained from 328 GPs (75%). At baseline, 92.1% of prescriptions were filled at pharmacies. The effect of the educational intervention was a 1% reduction in approximated risk (risk ratio [RR] 0.99, 95% confidence interval [CI] = 0.96 to 1.01) of antibiotics being dispensed, while the combined effect of the educational and pop-up reminder intervention was a 4% reduction in approximated risk (RR 0.96, 95% CI = 0.94 to 0.98). In the pop-up intervention group, 11.0% of the prescriptions were issued as delayed prescriptions and 59.2% of these were filled. Upper RTI, sinusitis, and otitis gave highest odds for delayed prescribing and lowest odds for dispensing. Conclusion Promoting delayed prescribing among GPs results in a small decrease in antibiotic dispensing. The savings potential is greatest for upper RTI, sinusitis, and otitis.

Most antibiotics are prescribed in primary care, and commonly for respiratory tract infections (RTIs). Narrow-spectrum phenoxymethylpenicillin is the antibiotic of choice for RTIs in the Scandinavian countries, while broader spectrum amoxicillin is used in most other European countries. This review summarizes the knowledge of the effect of phenoxymethylpenicillin versus amoxicillin for infections treated in ambulatory care. We searched PubMed/Medline and Embase for trials comparing the clinical effect of phenoxymethylpenicillin and amoxicillin. The Norwegian Knowledge Centre for the Health Services’ checklist was used to assess risk of bias. In total, 1687 studies were identified, and 18 of these fulfilled the inclusion criteria. One additional study was found as a reference. The randomized controlled trials revealed no significant differences in clinical effect in acute sinusitis (three RCTs), GAS tonsillitis (11 RCTs) and Lyme borreliosis (two RCTs). One RCT on community-acquired pneumonia found amoxicillin to be superior, while the results were conflicting in the two RCTs on acute otitis. The results suggest that non-Scandinavian countries should consider phenoxymethylpenicillin as the treatment of choice for RTIs because of its narrower spectrum. More studies should be conducted on the clinical effect of phenoxymethylpenicillin versus amoxicillin for acute otitis and lower RTIs.