Whenever my children get taken to the GP for a suspected chest/ear/throat/sinus infection, more often than not we are given a “back pocket”/delayed antibiotic prescription to be used only if the child does not improve over the next couple of days.
Is this a good policy?
My analytical way of thinking deduces the following assertions from the decision to prescribe a “back pocket” antibiotic prescription.
- The doctor has decided that based on the current clinical presentation, the patient doe not require an antibiotic immediately.
- The patient/guardian now has the primary responsibility as to whether the antibiotic is actually given or not. Is this really a good thing?
Studies have shown that back pocket prescriptions are acted upon about half the time, maybe a bit less than that. Whether or not a back pocket policy reduces antibiotic prescribing depends entirely on what you are comparing it against. If you say that all these patients would otherwise have received an antibiotic straightaway, then of course you can demonstrate a reduction! (Lies, damned lies and statistics…)
So what seems like a good idea may in reality may not be so perfect after all.
Given that only a small minority of such infections ever really need an antibiotic I prefer an educational approach (check out this leaflet), along with advice to come back if not settling in a couple of days’ time for clinical reassessment.
I remain to be convinced that back pocket prescriptions are a truly effective means of antimicrobial stewardship. To me it is more a way of the GP showing that they are doing something for the patient, a bit of a halfway house as such. It may even give out the completely wrong message to the patient. i.e. “I am not interested in seeing you again.”
If we are really serious about antimicrobial stewardship, then I think we need to review the back pocket policy. I think antibiotic prescribing for minor infections needs much tighter regulation. I also think including the clinical indication for the antibiotic on the prescription should be mandatory.
So the antibiotic prescription in my back pocket hardly ever comes out, and my gut feeling is that it shouldn’t even be there in the first place…
Here is an article with a bit more detail on this debate.