Use and feasibility of delayed prescribing for respiratory tract infections: A questionnaire survey
BMC Family Practice
Use and feasibility of delayed prescribing for respiratory tract infections: A questionnaire survey
Sigurd Hye 0
Jan C Frich 1
Morten Lindbaek 0
0 Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo , P.O.Box 1130 Blindern, N-0318 Oslo , Norway
1 Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo , Norway
Background: 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. Methods: Questionnaire survey among Norwegian GPs issuing and patients receiving a wait-and-see-prescription for RTIs. Patients reported symptoms, confidence and antibiotics consumption, GPs reported diagnoses, reason for issuing a wait-and-see-prescription and their opinion about the method. Results: 304 response pairs from consultations with 49 GPs were received. The patient response rate was 80%. The most common diagnosis for the GPs to issue a wait-and-see prescription was sinusitis (33%) and otitis (21%). 46% of the patients reported to consume the antibiotics. When adjusted for other factors, the diagnosis did not predict antibiotic consumption, but both being 16 years or more (p = 0,006) and reporting to have a fever (p = 0,012) doubled the odds of antibiotic consumption, while feeling very ill more than quadrupled the odds (p = 0,002). In 210 cases (69%), the GP found delayed prescribing a very reasonable strategy, and 270 patients (89%) would prefer to receive a wait-and-see prescription in a similar situation in the future. The GPs found delayed prescribing very reasonable most frequently in cases of sinusitis (79%, p = 0,007) and least frequently in cases of lower RTIs (49%, p = 0,002). Conclusion: Most patients and GPs are satisfied with the delayed prescribing strategy. The patients' age, symptoms and malaise are more important than the diagnosis in predicting antibiotic consumption. The GP's view of the method as a reasonable approach depends on the patient's diagnosis. In our setting, delayed prescribing seems to be a feasible strategy, especially in cases of sinusitis and otitis. Educational efforts to promote delayed prescribing in similar settings should focus on these diagnoses.
General practitioners (GPs) issue more than 90% of
antibiotic prescriptions in Norway, and about 60% of
these are issued for common respiratory tract infections
(RTIs) . RTIs are often self-limiting, and antibiotics
have a modest role in the treatment of such conditions
. Unnecessary use of antibiotics is a global concern,
as it leads to antibiotic resistance, adverse drug
reactions, and medicalization of self-limiting disease.
Antibiotic prescription rates are relatively low in Norway
and other Northern European countries , but a recent
Norwegian prescription study found that there still is
room for improvement .
Much effort has been put into developing strategies to
reduce over-consumption of antibiotics for RTIs in
general practice, and randomized controlled trials have
provided evidence for delayed prescribing as an effective
strategy. Reported pick up rates for wait-and-see
prescriptions varies from 24 - 38% (otitis media) [5,6], 31%
(sore throat) , 20 - 45% (cough) [8,9], to 48%
(common cold) . The safety of the method seems to be
good, and there is probably no increase in complication
rates, but a longer duration of certain symptoms in
some studies .
It has been argued that delaying antibiotics has little
advantage over avoiding them where it is safe to do so
. However, the question regarding safety in handling
RTIs is not clear cut, and factors like physician
insecurity, patient demands and work load lead GPs to
prescribe antibiotics without a good medical indication
. GPs experience numerous situations where they
find delayed prescribing reasonable . Hence, delayed
prescribing might have an important place in the
management of RTIs . The strategy is recommended in
several national treatment guidelines on RTIs in general
practice [15-17], and it is part of the intervention in
quality improvement studies on appropriate antibiotics
Delayed prescribing is not universally endorsed by GPs
[13,21], though patients seem to be confident and
satisfied with wait-and-see prescriptions [7,22]. When
advocating treatment innovations to improve quality of care,
the feasibility and credibility of the innovation must be
taken into account . There is a lack of knowledge
on if, and in which situations, GPs find delayed
prescribing a reasonable approach, and in which situations GPs
choose to use the strategy.
The aim of this study is 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 perspective.
The terms delayed prescribing and wait-and-see
prescription are used synonymously in the literature. In
this paper we use delayed prescribing for the strategy,
and wait-and-see prescription denotes the prescription
Subjects and setting
We translated and adopted a questionnaire on patients
response to delayed prescription used in a previous
study , and developed a questionnaire on GPs
reasons for issuing wait-and-see prescriptions.
The study was conducted as a part of the Prescription
Peer Academic Detailing (Rx-PAD) Study, a
cluster-randomized educational intervention study in Norwegian
general practice with the aim of improving antibiotic
prescribing in respiratory tract infections . The
elements of the intervention were educational outreach
visits to the participants continuing medical education
groups comprising presentation and discussion of
evidence-based antibiotics prescribing for RTIs, collection
of individual prescription data, audit based on individual
feedback reports, as well as a one-day regional seminar.
As part of the seminar, one of the authors (SH) gave a
lecture on the evidence regarding delayed prescribing,
and invited the GPs to recruit patients to the present
study. 58 GPs agreed to participate. In addition, 16 GPs
affiliated to the Department of General Practice,
University of Oslo, were given the same lecture, and agreed to
participate (Figure 1).
Eligible patients were those of any age who consulted
the GP for a RTI, and to whom the GP found it
appropriate to offer a wait-and-see prescription. In the course
of the consultation, the GP handed the patient an
antibiotic prescription together with a patient questionnaire,
a consent form, an information leaflet and a
prestamped envelope. The patient was instructed to wait
for a certain amount of time, chosen by the GP, before
deciding whether to take the antibiotics or not. The
questionnaire was to be filled once the patient had
made this decision. After the consultation, the doctor
filled in the GP questionnaire. Patients were rewarded
with a scratchcard upon responding, while the GP
would receive a gift card for a CD when they had
recruited 10 patients. Recruitment took place during
April 2006 through June 2008.
The Regional Committee for Research Ethics in Oslo,
Norway, approved the study (S-05272).
Chi square test was used to compare those patients who
reported to consume antibiotics and those who did not,
with regard to both patient factors (demographic
characteristics, presenting symptoms, expectations,
confidence in deciding whether to use the prescription) and
GP factors (diagnose, reason for giving wait-and-see
prescription, reasonableness, and impression of
expectations and use of the prescription). Logistic regression
analysis was performed with the dependent variable
being whether the patient reported to consume the
antibiotics or not. Further, we compared cases where the
GP found delayed prescribing very reasonable and cases
where where the GP did not. A significance level of 5%
was applied. Analyses were performed using SPSS 14
Out of a total of 68 GPs, 49 (72%) recruited on average
8.5 patients each (median 6; span 1-34). 19 (28%) GPs
recruited no patients. We received 413 responses from
GPs and 332 responses from patients. Five patients
informed that they did not want to participate, and
consequently we removed the corresponding GPs responses.
For five of the patient responses, we did not receive a
corresponding GPs response, resulting in 327 response
pairs and a patient response rate of 80%.
A total of 49 GPs
203 GPs participating in
the Rx-PAD Study.
150 GPs attending the
seminar and invited to
participate in the present
58 GPs agreed to
Figure 1 Flowchart representing GP recruitment.
17 response pairs were excluded because the GPs had
included patients who were treated for other conditions
than RTIs, and an additional six response pairs were
excluded because the patients failed to answer whether
they had taken antibiotics. 304 response pairs remained
We grouped diagnoses according to previouos studies
on RTIs [1,24]. Table 1 displays the characteristics of
the participating patients and GPs.
Table 1 Characteristics of participating patients and GPs
16 GPs affiliated to the
Department of General
Practice, University of
Oslo, invited to participate
in the present study.
Comparison of responders and non-responders
Of the 81 non-responding patients, there were
significantly more men (47% vs 33%) and more patients with
upper RTIs (34% vs 20%), compared to the group of
Delayed prescribing - when and why
Table 2 shows the diagnoses given by the GPs when
issuing a wait-and-see prescription, and the diagnose
groups used in the further analysis. In comparison with
a reference material of antibiotic prescribing for
respiratory tract infections in a Norwegian county during two
winter months in 2003, our material shows an
overrepresentation of sinusitis (33,2% vs 14,6%) and otitis
(21,4% vs 9,1%), and an underrepresentation of lower
RTI (13,5% vs 28,5%) and tonsillitis (7,9% vs 16,8%).
The majority (58%) of the children given a
wait-andsee-prescription had otitis, while the majority (49%) of
adults had sinusitis, and the elderly had lower RTI
(46%). Patients with the diagnosis of upper RTI reported
feeling more ill (p = 0,009), and patients with tonsillitis
felt less ill (p = 0,04) compared to patients with other
The GPs reported that they issued wait-and-see
prescriptions mainly because of uncertainty about the
indication for antibiotics (211 cases, 69%) or uncertainty
about the diagnose (32 cases, 11%). (See also table 4).
Difficulties connected to follow up was given as reason
in 29 cases (10%), and disagreement with the patient on
Table 2 Diagnoses where GPs issued delayed prescription, compared to a reference material of antibiotic prescriptions
for respiratory tract infections
the need for antibiotics in 12 cases (4%). In 44 cases
(14%), the GP reported Other reasons, and in 34 of
these cases, this was the only explanation for issuing the
wait-and-see prescription. Other reasons were in all
but one case described as clinical or therapeutic
peculiarities in the specific situation (eg. mild symptoms,
pregnancy, short duration of symptoms, other treatment
Factors associated with the decision to consume
141 (46%) of the patients reported to consume the
antibiotics. Diagnoses and patients factors associated with
consumption of antibiotics are presented in table 3.
There were no statistically significant differences
between those who reported to have consumed
antibiotics and those who did not in respect of their gender or
their educational level.
Patients diagnosed with an ear infection were less
likely to consume antibiotics. Patients younger than 16
years were less likely to consume antibiotics (p = 0,04).
When reporting to have fever, patients were more likely
to consume antibiotics (p = 0,012). Also, a higher
number of reported symptoms (p = 0,024) and more malaise
(p = 0,012) made patients more likely to consume
The prognostic variables in table 3 resulting in a
pvalue of 0,25 or less were included in a logistic
regression analysis, together with the background
characteristics age, gender and educational level, the dependent
variable being whether the patient reported to consume
the antibiotics or not (Table 4). Symptom sum was not
included, as this variable was closely correlated to, and
also included, the individual symptoms. Four factors
were significantly associated with consuming antibiotics.
Having a fever, reporting to be very ill and being of
older age increased the odds, while a nasal congestion
decreased the odds of consuming antibiotics.
When asked whether they thought the patient would
take the antibiotics, the GPs answered yes in 51 (17%)
of the cases, no in 131 (43%) of the cases and that they
were uncertain in 122 (40%) of the cases. The GPs
presumption was slightly correlated with the patients
reported action (p = 0,025, correlation coefficient 0,166).
Feasibility of delayed prescribing
262 (86%) out of the 304 patients stated that they felt
confident in deciding whether to use the prescription,
a Percentages within the brackets are those within the patient group.
b Pearson chi-square.
Table 4 Logistic multivariate regression analysis
Patient expectations b
1,39 (0,88 - 2,18)
1,56 (0,81 - 2,98)
0,66 (0,36 - 1,24)
1,94 (1,15 - 3,27)
0,58 (0,34 - 0,99)
Odds ratio for reporting to consume the antibiotics.
a The odds ratios are adjusted for the background characteristics and for the other surviving variables in the model.
b The reference value is not having the spesific symptom/expectation.
12 patients (4%) felt unconfident, and the remaining 30
patients (10%) felt neither. There were no significant
correlations between confidence and certain diagnosis
or prescription pick up rate. 270 patients (89%) would
prefer to receive a wait-and-see prescription in a similar
situation in the future, nine patients (3%) would prefer
not to be offered delayed prescribing, whereas 24
patients (8%) were uncertain what they preferred.
Patients with upper RTI did to a lesser extent wish for
delayed prescribing in the future (48/60, 80%, p =
Out of the 163 patients stating not to consume the
antibiotics, 64 (39%) reported to have saved the
prescription or the medication for later.
In 210 (69%) of the cases, the GPs answered that they
viewed delayed prescribing a very reasonable approach
in the specific clinical setting. In 90 cases (30%) they
found the approach fairly reasonable, and in four cases
(1%) they expressed to be uncertain on this subject.
Table 5 presents factors associated with GPs finding
delayed prescribing a reasonable strategy.
12 wait-and-see prescriptions from 10 different GPs
were issued because of disagreement with the patient. In
three of these cases (25%), the GP found the method
very reasonable, as opposed to 71% when the
wait-andsee prescription was issued for other reasons.
In sinusitis, the GPs found delayed prescribing very
reasonable in 79% of the cases. At the opposite, the GPs
Table 5 GPs opinion of delayed prescribing as a reasonable strategy
Diagnosis group n = 304
Upper respiratory tract symptoms and infections 60 (20)
Lower respiratory tract infections 41 (14)
Ear infections 65 (21)
Sinusitis 101 (33)
Acute tonsillitis 24 (8)
Other respiratory diagnoses 13 (4)
GPs reason for giving delayed prescription n = 304
Uncertainty about indication for antibiotics 211 (69)
Other reason 44 (14)
Uncertainty about diagnose 32 (11)
Difficulties with follow up 29 (10)
Disagreement with the patient 12 (4)
GPs expectation n = 304
Patient is likely to take antibiotics 51 (17)
Patient is not likely to take antibiotics 131 (43)
Uncertain 122 (40)
GPs impression of patients antibiotics expectation n = 303 (209/94)
Patient expected antibiotics 73 (24)
Patient did not expect antibiotics 150 (50)
Uncertain 80 (26)
Grouped age (years) n = 304
Less than 16 100 (33)
16-59 180 (59)
60 and over 24 (8)
Gender n = 304
Female 204 (67)
Male 100 (33)
a Pearson chi-square.
found the method very reasonable in 49% of the lower
RTI-cases. The GPs found delayed prescribing more
reasonable when they thought the patient would not fill in
the prescription (p = 0.017).
Summary of main findings
General practitioners who have been informed about the
use of wait-and-see prescriptions in RTIs, most often
use the strategy in cases of acute sinusitis and acute
otitis media. These are also the diagnoses for which the
GPs find the strategy most reasonable. The reported
reason for issuing a wait-and-see prescription is most
commonly uncertainty about indication for antibiotics.
Patients receiving a wait-and-see prescription are
confident in the decision whether to start taking the
medication, and half of the patients report to consume the
antibiotics. Feeling very ill, having fever, and being more
than 16 years predict consumption of antibiotics, while
Wait-and-see Rx very
(n = 210)
Wait-and-see Rx not
very reasonable (%)
(n = 94)
Very reasonable % P-value a
reporting nasal congestion is negatively associated with
Comparison with existing litterature
To our knowledge, this is the first survey on delayed
prescribing in which different diagnoses are compared,
and in which the feasability of the strategy among GPs
We found that GPs issue wait-and-see prescription
most commonly in sinusitis and otitis. When compared
to a similar group of GPs in Norway , our numbers
show an over-representation of sinusitis and otitis,
which indicates that patients receiving antibiotics for
otitis or sinusitis more often will be instructed to wait
than patients receiving antibiotics for other conditions.
This may be because otitis and sinusitis are the two
conditions for which the Norwegian National Treatment
Guidelines recommend watchful waiting . A
Norwegian prescription study shows that tonsilitis is the
diagnosis that would most often warrant a prescription
for antibiotics, while URTI is at the other extreme .
This may explain why patients with tonsilitis in our
study felt less ill, and patients with URTI felt more ill,
as one could assume that the moderately ill patients
with tonsilitis would be given an immediate prescription
for antibiotics, and the moderately ill patients with
URTI would not be given antibiotics at all.
The first evidence on the advantages of delayed
prescribing came from studies on patients with sore throat
in the United Kingdom in 1997 , and the spreading
of this evidence is considered as one of the reasons why
antibiotic consumption continued to decrease in the UK
from the late 1990s and onwards . However, in our
study sore throat is not a condition in which the GPs
readily give wait-and-see prescriptions. This may be due
to the widespread use of point-of-care streptococcal
throat tests in Norwegian general practice , and that
the GPs let the test results decide whether to prescribe
In our study, 46% of the patients reported to consume
the antibiotics and 86% reported confidence in deciding
whether to take the antibiotics. These findings are
similar to Edwards et al, who in a comparable British study
 found a consumption rate of 53%, and 87%
confident patients. In both studies, fever was found as a
predictor for consuming antibiotics. Fever is shown to be
the most important cue when parents take treatment
decisions on behalf of their sick child .
There were some interesting differences regarding
patient expectations. Fewer patients in our study
expected antibiotics (52%) compared to the findings of
Edwards et al (65%). This may be due to a real
difference in antibiotic expectation, despite similar antibiotic
prescription rates in the two countries . Another
explanation may be that the GPs in our study to a lesser
degree used delayed prescribing as a tool to meet
patient expectation for antibiotics. Substantially more
patients in our setting expected tests or referral (50% vs
Edwards et al: 2%). This indicates that the more
widespread use of point-of-care tests in our setting
compared to Edwards et als UK setting  has had an
influence on patients expectations.
We found differences in reported consumption rates
for the various diagnoses, and the internal variation
shows some resemblence with the results achieved in
various diagnose-specific RCTs on delayed prescribing;
35% vs 24 - 38% (otitis media) [5,6], 46% vs 31% (sore
throat) , 51% vs 20 - 45% (lower RTI/cough) [8,9],
and 57% vs 48% (upper RTI/common cold) . The
results are understandably not directly comparable, as
the methods of issuing delayed prescriptions differ
between various studies, the diagnostic criteria varies,
and the antibiotic prescription rates  and the patients
views on respiratory tract infections show great variance
between countries . Nevertheless, the variance
between diagnose groups in our study may give valuable
information as the prescriptions for various conditions
were given in the same setting.
The natural course of otitis in children is a
spontaneous recovery after a few days in approximately 80% of
the cases , whereas other RTIs may not have this
sudden relief. This might explain why ear infection is
the diagnose with the lowest pick up rate.
The overall satisfaction with delayed prescribing was
high both among GPs and patients. GPs consider
overuse of antibiotics a problem , and may feel
uncomfortable prescribing antibiotics . Thus, there is no
surprise that GPs in our study found wait-and-see
prescriptions most reasonable among patients who they
thought would not pick it up.
Although small numbers, our findings suggest that
GPs find delayed prescribing more reasonable in
situations of clinical uncertainty rather than in situations
where patients demand antibiotics, which is in
accordance with the findings in a previous, qualitative study
among a similar group of GPs .
The GPs found delayed prescribing most reasonable in
cases of otitis and sinusitis while the strategy was less
valued in cases of upper and lower respiratory tract
infections. This may also, as suggested above, be due to
the difference in the current understanding and
recommended treatment of the various conditions; indication
for antibiotics in otitis and sinusitis depends partly,
according to Norwegian guidelines, on the duration of
symptoms. When it comes to bronchitis and
URTI/common cold, the main recommendation is to avoid
antibiotics altogether. This might explain why these diagnoses
were found less appropriate for delayed prescribing.
Strengths and limitations
The response rate (80%) was relatively high in
comparison to a previous study . The aim of this study was
not to explore clinical outcomes and safety of the
delayed prescribing strategy, and potential differences in
treatment outcomes for different diagnoses have not
This study does not allow to directly compare the use
of wait-and-see prescriptions with the use of
prescriptions for antibiotics to be taken immediately, since we
have no record of the latter. For illustrative means, we
have compared our findings with a reference material of
antibiotic prescriptions for RTIs during two winter
The participating GPs had agreed to take part in a
study on delayed prescribing, and they might hold a
more positive view towards the strategy compared to
the relatively large group of invited GPs who did not
participate. However, both high and low prescribers of
wait-and-see-prescriptions were represented.
As in all questionnaire surveys, our results depend on
the respondents report, and not necessarily on their
action. The patient questionnaire and information leaflet
were carefully constructed to avoid an impression that
not picking up the prescription would be the preferred
solution, so as to minimize a desirability bias. Still, the
reported antibiotics consumption rate of 46% may be a
underreporting of what actually happened.
The diagnoses referred in this study are the ones
chosen by the GPs. We do not know if, and to what extent,
diagnostic criteria were followed, and the diagnostic
accuracy may have varied between the different GPs.
Most patients and GPs are satisfied with the delayed
prescribing strategy. The patients age, symptoms and
malaise are more important than the diagnosis in
predicting antibiotic consumption. The GPs view of the
method as a reasonable approach depends on the
patients diagnosis. In our setting, delayed prescribing
seems to be a feasible strategy, especially in cases of
sinusitis and otitis. Educational efforts to promote
delayed prescribing in similar settings should focus on
We would like to thank Martin Edwards for sharing his patient questionnaire
form. We are grateful to the GPs and patients who participated in this study.
This study was funded by a research scholarship from The General Practice
Research Fund, The Norwegian Medical Association. The funding body had
no role in study design, the collection, analysis, and interpretation of data,
the writing of the article or the decision to submit it for publication.
SH and ML conceived and designed the study. SH collected and analysed
the data and wrote the draft manuscript. All authors interpreted the data,
critically revised the draft for important intellectual content, prepared the
manuscript, and gave final approval of the version to be published.
ML edited and SH took part in developing the Norwegian National
guidelines for antibiotic use in primary health care 2008.
The authors declare that they have no competing interests.
1. Straand J , Rokstad KS , Sandvik H : Prescribing systemic antibiotics in general practice . A report from the More & Romsdal Prescription Study. Scand J Prim Health Care 1998 , 16 ( 2 ): 121 - 127 .
2. Arroll B : Antibiotics for upper respiratory tract infections: an overview of Cochrane reviews . Respir Med 2005 , 99 ( 3 ): 255 - 261 .
3. Goossens H , Ferech M , Vander SR , Elseviers M : Outpatient antibiotic use in Europe and association with resistance: a cross-national database study . Lancet 2005 , 365 ( 9459 ): 579 - 587 .
4. Gjelstad S , Dalen I , Lindbaek M : GPs' antibiotic prescription patterns for respiratory tract infections - still room for improvement . Scand J Prim Health Care 2009 , 27 ( 4 ): 208 - 215 .
5. Little P , Gould C , Williamson I , Moore M , Warner G , Dunleavey J : Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media . BMJ 2001 , 322 ( 7282 ): 336 - 342 .
6. Spiro DM , Tay KY , Arnold DH , Dziura JD , Baker MD , Shapiro ED : Wait-andsee prescription for the treatment of acute otitis media: a randomized controlled trial . JAMA 2006 , 296 ( 10 ): 1235 - 1241 .
7. Little P , Williamson I , Warner G , Gould C , Gantley M , Kinmonth AL : Open randomised trial of prescribing strategies in managing sore throat . BMJ 1997 , 314 ( 7082 ): 722 - 727 .
8. Dowell J , Pitkethly M , Bain J , Martin S : A randomised controlled trial of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care . Br J Gen Pract 2001 , 51 ( 464 ): 200 - 205 .
9. Little P , Rumsby K , Kelly J , Watson L , Moore M , Warner G , et al: Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial . JAMA 2005 , 293 ( 24 ): 3029 - 3035 .
10. Arroll B , Kenealy T , Kerse N : Do delayed prescriptions reduce the use of antibiotics for the common cold? A single-blind controlled trial . J Fam Pract 2002 , 51 ( 4 ): 324 - 328 .
11. Spurling GK , Del Mar CB , Dooley L , Foxlee R : Delayed antibiotics for respiratory infections . Cochrane Database Syst Rev 2007 , , 3 : CD004417 .
12. Petursson P : GPs' reasons for non-pharmacological prescribing of antibiotics. A phenomenological study . Scand J Prim Health Care 2005 , 23 ( 2 ): 120 - 125 .
13. Hye S , Frich JC , Lindbaek M : Delayed prescribing for upper respiratory tract infections: a qualitative study of general practitioners' views and experiences . Br J Gen Pract 2010 , 60 ( 581 ): 907 - 912 .
14. Little P : Delayed prescribing of antibiotics for upper respiratory tract infection . BMJ 2005 , 331 ( 7512 ): 301 - 302 .
15. Prescribing of antibiotics for self limiting respiratory tract infections in adults and children in primary care . National Institute for Health and Clinical Excellence ; 2008 , Clinical Guideline 69.
16. The Directorate of Health, The antibiotic center for primary helath care: [National guidelines for antibiotic use in primary health care] . Oslo: The Directorate of Health ; 2008 .
17. STRAMA, Medical Products Agency: [Diagnostics, treatment and follow-up of acute otitis media (AOM) - new recommendation] . Information from the Medical Products Agency 2010 , 21 ( 5 ): 13 - 24 .
18. Gjelstad S , Fetveit A , Straand J , Dalen I , Rognstad S , Lindbaek M : Can antibiotic prescriptions in respiratory tract infections be improved? A cluster-randomized educational intervention in general practice-the Prescription Peer Academic Detailing (Rx-PAD) Study [NCT00272155] . BMC Health Serv Res 2006 , 6 : 75 .
19. McDermott L , Yardley L , Little P , Ashworth M , Gulliford M , Research Team: Developing a computer delivered, theory based intervention for guideline implementation in general practice . BMC Fam Pract 2010 , 11 ( 1 ): 90 .
20. Simpson SA , Butler CC , Hood K , Cohen D , Dunstan F , Evans MR , et al: Stemming the Tide of Antibiotic Resistance (STAR): a protocol for a trial of a complex intervention addressing the 'why' and 'how' of appropriate antibiotic prescribing in general practice . BMC Fam Pract 2009 , 10 : 20 .
21. Arroll B , Goodyear-Smith F , Thomas DR , Kerse N : Delayed antibiotic prescriptions: what are the experiences and attitudes of physicians and patients? J Fam Pract 2002 , 51 ( 11 ): 954 - 959 .
22. Edwards M , Dennison J , Sedgwick P : Patients' responses to delayed antibiotic prescription for acute upper respiratory tract infections . Br J Gen Pract 2003 , 53 ( 496 ): 845 - 850 .
23. Grol R , Wensing M : What drives change? Barriers to and incentives for achieving evidence-based practice . Med J Aust 2004 , 180 ( 6 Suppl): S57 - S60 .
24. Gjelstad S , Dalen I , Lindbaek M : GPs' antibiotic prescription patterns for respiratory tract infections-still room for improvement . Scand J Prim Health Care 2009 , 27 ( 4 ): 208 - 215 .
25. Sharland M , Kendall H , Yeates D , Randall A , Hughes G , Glasziou P , et al: Antibiotic prescribing in general practice and hospital admissions for peritonsillar abscess, mastoiditis, and rheumatic fever in children: time trend analysis . BMJ 2005 , 331 ( 7512 ): 328 - 329 .
26. Fagan M : [ Is otitis and tonsillitis handled in the same way within normal working hours and out-of-hours?] . Tidsskr Nor Laegeforen 2008 , 128 ( 20 ): 2340 - 2342 .
27. Lagerlov P , Loeb M , Slettevoll J , Lingjaerde OC , Fetveit A : Severity of illness and the use of paracetamol in febrile preschool children; a case simulation study of parents' assessments . Fam Pract 2006 , 23 ( 6 ): 618 - 623 .
28. Butler CC , Simpson S , Wood F : General practitioners' perceptions of introducing near-patient testing for common infections into routine primary care: a qualitative study . Scand J Prim Health Care 2008 , 26 ( 1 ): 17 - 21 .
29. Deschepper R , Vander Stichele RH , Haaijer-Ruskamp FM : Cross-cultural differences in lay attitudes and utilisation of antibiotics in a Belgian and a Dutch city . Patient Educ Couns 2002 , 48 ( 2 ): 161 - 169 .
30. Glasziou PP , Del Mar CB , Sanders SL , Hayem M : Antibiotics for acute otitis media in children . Cochrane Database Syst Rev 2004 , , 1 : CD000219 .
31. Simpson SA , Wood F , Butler CC : General practitioners' perceptions of antimicrobial resistance: a qualitative study . J Antimicrob Chemother 2007 , 59 ( 2 ): 292 - 296 .
32. Bradley CP : Uncomfortable prescribing decisions: a critical incident study . BMJ 1992 , 304 ( 6822 ): 294 - 296 .