***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Although a reduction has occurred in the use of antibiotics for upper respiratory tract infections , international evidence indicates that they continue to be used for these conditions.1 This is in spite of Cochrane review s indicating minimal or no benefit from antibiotics for sore throat , acute bronchitis , the common cold , and otitis media . This situation of potentially inappropriate prescribing prompted one commentator to suggest the use of delayed prescriptions ( also known as “ back-pocket , ” “ back-up , ” or “ as needed ” prescriptions).2 These are prescriptions written with a proviso that they not be used immediately and only if symptoms do not improve . The first r and omised trial of delayed prescriptions for respiratory symptoms was undertaken by Little et al ( 1997 ) , who gave antibiotics , with the prescription to be filled immediately or after three days , or no antibiotics for acute sore throat.3 The immediate group filled 99 % of the antibiotic prescriptions whereas the delayed group filled only 31 % with no apparent serious harms . In the group not given any antibiotics 13 % ended up filling an antibiotic prescription after a return visit to the doctor . Critics of delayed prescriptions say that the strategy increases the use of antibiotics by comparing the 13 % with the 31 % . This is not how we see the use of delayed prescriptions . Their use should be restricted to those patients who request antibiotics or whom their doctor thinks they want an antibiotic yet does not think one is immediately indicated . However , only one of the r and omised trials has examined such a specific group.4 Five controlled trials of delayed prescriptions have been published , conducted in patients with otitis media,5,6 sore throat,3 cough lasting seven days,7 and the common cold.4 In three trials the patients in the delayed prescription arm had more symptoms during the trial , which implies that patients are willing to tolerate some symptoms to avoid antibiotics.3,6,7 Ironically the study with the highest reduction in relative risk ( 75 % ) was the study in children with otitis media , in spite of the children having more symptoms.6 We speculate that parents may be more concerned about avoiding antibiotics in their children than in themselves — a view supported by a qualitative study of patients with sore throat.8 The largest reductions in antibiotic consumption occurred in the three studies which required patients to return to the surgery to collect the prescriptions.3,6,7 Although most of the studies had pick-up suggestions of three days or less , the study on acute cough , which suggested waiting seven days , still produced a reduction in relative risk of 55 % . An additional benefit of delayed prescriptions may be a reduction in repeat visits , at least for sore throat.9 The reduction in usage of antibiotics for infections of the upper respiratory tract through using delayed prescriptions is as effective as , and in many cases more effective than , educational projects.10 - 11 However , no studies have directly compared delayed prescriptions with educational projects . Some interesting insights have been obtained from qualitative work in patients and doctors on delayed prescriptions.12  Not all general practitioners endorsed the use of delayed prescriptions — some had concerns that they may be missing or masking serious illness , with concomitant medicolegal issues . Some worried that their patients may consider them incompetent . General practitioners thought that the positive aspects of delayed prescriptions included avoiding side effects , reducing the drug bill , educating patients , and involving patients in decision making . Although reducing antibiotic resistance was a major issue for general practitioners it was not a concern for patients .12 More education for patients around this issue may be warranted , and we suggest that the delayed prescription be used as a tool to help improve patients ' knowledge about infectious disease and awareness of the need for monitoring their own progress . Research is also needed on other methods of providing a barrier other than a patient 's return to the practice if he or she is not getting better . Such barriers could be asking patients to wait seven days rather than three and post-dating prescriptions . If delayed prescriptions are to become routine then surgeries will need to have systems to hold the prescription at the front desk and to allow patients easy access for re assessment if concerned about their symptoms . They may also need to consider following up patients with delayed prescriptions to monitor adverse events . In the qualitative research on delayed prescriptions several general practitioners no longer used this strategy , once their patients had become “ trained ” not to expect antibiotics . As prescribing becomes more rational the need for delayed prescriptions for respiratory tract infections may in time become redundant Abstract Objective : To assess three prescribing strategies for sore throat .  Design : R and omised follow up study . Setting : 11 general practice s in the South and West region . Subjects : 716 patients aged 4 years and over with sore throat and an abnormal physical sign in the throat ; 84 % had tonsillitis or pharyngitis . Patients were r and omised to three groups : prescription for antibiotics for 10 days ( group 1 , 246 patients ) ; no prescription ( group 2 , 230 patients ) ; or prescription for antibiotics if symptoms were not starting to settle after three days ( group 3 ; 238 patients ) . Main outcome measures : Duration of symptoms ; satisfaction and compliance with and perceived efficacy of antibiotics ; time off school or work . Outcomes were documented in 582 subjects ( 81 % ) . Results : Median duration of antibiotic use differed significantly in the three groups ( 10 v 0 v 0 days , P<0.001 ) ; 69 % of patients in group 3 did not use their prescription . The proportion of patients better by day 3 did not differ significantly ( 37 % v 35 % v 30 % , P=0.28 ) , nor did the duration of illness ( median 4 v 5 v 5 days , P=0.39 ) , days off work or school ( median 2 v 2 v 1 , P=0.13 ) , or proportion of patients satisfied ( 96 % v 90 % v 93 % , P=0.09 ) , although group 1 had fewer days of fever ( median 1 v 2 v 2 days , P=0.04 ) . More patients in group 1 thought the antibiotics were effective ( 87 % v 55 % v 60 % , P<0.001 ) and intended coming to the doctor in future attacks ( 79 % v 54 % v 57 % , P<0.001 ) . “ Legitimation ” of illness — to explain to work or school ( 60 % ) or family or friends (37%)–was an important reason for consultation . Patients who were more satisfied got better more quickly , and satisfaction related strongly to how well the doctor dealt with patient 's concerns . Conclusion : Prescribing antibiotics for sore throat only marginally affects the resolution of symptoms but enhances belief in antibiotics and intention to consult in future when compared with the acceptable strategies of no prescription or delayed prescription . Psychosocial factors are important in the decision to see a general practitioner and in predicting the duration of illness . Key messages Sore throat is one of the commonest presentations of upper respiratory illness to general practitioners , and attendance is increasing Prescribing antibiotics for sore throat does not reduce the extent and duration of symptoms Prescribing antibiotics enhances belief in antibiotics and intention to consult Legitimation of illness is an important reason for attending the doctor Satisfaction predicts duration of illness and closely relates to how well concerns are dealt with — unless patients are very ill , general practitioners should consider exploring concerns and should avoid or delay prescribing IMPORTANCE Delayed antibiotic prescription helps to reduce antibiotic use with reasonable symptom control . There are different strategies of delayed prescription , but it is not yet clear which one is the most effective . OBJECTIVE To determine the efficacy and safety of 2 delayed strategies in acute , uncomplicated respiratory infections . DESIGN , SETTING , AND PARTICIPANTS We recruited 405 adults with acute , uncomplicated respiratory infections from 23 primary care centers in Spain to participate in a pragmatic , open-label , r and omized clinical trial . INTERVENTIONS Patients were r and omized to 1 of 4 potential prescription strategies : ( 1 ) a delayed patient-led prescription strategy ; ( 2 ) a delayed prescription collection strategy requiring patients to collect their prescription from the primary care center ; ( 3 ) an immediate prescription strategy ; or ( 4 ) a no antibiotic strategy . Delayed prescription strategies consist of prescribing an antibiotic to take only if the symptoms worsen or if there is no improvement several days after the medical visit . MAIN OUTCOMES AND MEASURES The primary outcomes were the duration of symptoms and severity of symptoms . Each symptom was scored using a 6-point Likert scale ( scores of 3 or 4 were considered moderate ; 5 or 6 , severe ) . Secondary outcomes included antibiotic use , patient satisfaction , and patients ' beliefs in the effectiveness of antibiotics . RESULTS A total of 405 patients were recruited , 398 of whom were included in the analysis ; 136 patients ( 34.2 % ) were men ; mean ( SD ) age , 45 ( 17 ) years . The mean severity of symptoms ranged from 1.8 to 3.5 points on the Likert scale , and mean ( SD ) duration of symptoms described on first visit was 6 ( 6 ) days . The mean ( SD ) general health status on first visit was 54 ( 20 ) based on a scale with 0 indicating worst health status ; 100 , best status . Overall , 314 patients ( 80.1 % ) were nonsmokers , and 372 patients ( 93.5 % ) did not have a respiratory comorbidity . The presence of symptoms on first visit was similar among the 4 groups . The mean ( SD ) duration of severe symptoms was 3.6 ( 3.3 ) days for the immediate prescription group and 4.7 ( 3.6 ) days for the no prescription group . The median ( interquartile range [ IQR ] ) of severe symptoms was 3 ( 1 - 4 ) days for the prescription collection group and 3 ( 2 - 6 ) days for the patient-led prescription group . The median ( IQR ) of the maximum severity for any symptom was 5 ( 3 - 5 ) for the immediate prescription group and the prescription collection group ; 5 ( 4 - 5 ) for the patient-led prescription group ; and 5 ( 4 - 6 ) for the no prescription group . Patients r and omized to the no prescription strategy or to either of the delayed strategies used fewer antibiotics and less frequently believed in antibiotic effectiveness . Satisfaction was similar across groups . CONCLUSIONS AND RELEVANCE Delayed strategies were associated with slightly greater but clinical ly similar symptom burden and duration and also with substantially reduced antibiotic use when compared with an immediate strategy . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01363531 Background In North America , although it varies according to the specific type of acute respiratory infections ( ARI ) , use of antibiotics is estimated to be well above the expected prevalence of bacterial infections . The objective of this pilot clustered r and omized controlled trial ( RCT ) is to assess the feasibility of a larger clustered RCT aim ing at evaluating the impact of DECISION+ , a continuing professional development ( CPD ) program in shared decision making , on the optimal use of antibiotics in the context of ARI . Methods / design This pilot study is a cluster RCT conducted with family physicians from Family Medicine Groups ( FMG ) in the Quebec City area , Canada . Participating FMG are r and omised to an immediate DECISION+ group , a CPD program in shared decision making , ( experimental group ) , or a delayed DECISION+ group ( control group ) . Data collection involves recruiting five patients consulting for ARI per physician from both study groups before ( Phase 1 ) and after ( Phase 2 ) exposure of the experimental group to the DECISION+ program , and after exposure of the control group to the DECISION+ program ( Phase 3 ) . The primary outcome measures to assess the feasibility of a larger RCT include : 1 ) proportion of contacted FMG that agree to participate ; 2 ) proportion of recruited physicians who participate in the DECISION+ program ; 3 ) level of satisfaction of physicians regarding DECISION+ ; and 4 ) proportion of missing data in each data collection phase . Levels of agreement of the patient-physician dyad on the Decisional Conflict Scale and physicians ' prescription profile for ARI are performed as secondary outcome measures . Discussion This study protocol is informative for research ers and clinicians interested in design ing and /or conducting clustered RCT with FMG regarding training of physicians in shared decision making . Trial Registration Clinical Trials.gov Identifier : Objective To assess the impact on adverse outcomes of different antibiotic prescribing strategies for lower respiratory tract infections in people aged 16 years or more . Design Prospect i ve cohort study . Setting UK general practice . Participants 28 883 patients with lower respiratory tract infection ; symptoms , signs , and antibiotic prescribing strategies were recorded at the index consultation . Main outcome measures The main outcomes were reconsultation with symptoms of lower respiratory tract infection in the 30 days after the index consultation , hospital admission , or death . Multivariable analysis controlled for an extensive list of variables related to the propensity to prescribe antibiotics and for clustering by doctor . Results Of the 28 883 participants , 104 ( 0.4 % ) were referred to hospital for radiographic investigation or admission , or both on the day of the index consultation , or were admitted with cancer . Of the remaining 28 779 , subsequent hospital admission or death occurred in 26/7332 ( 0.3 % ) after no antibiotic prescription , 156/17 628 ( 0.9 % ) after pres 
    Output:
    
One study favoured delayed antibiotics over no antibiotics for pain , fever , and cough duration ( moderate quality evidence for all clinical outcomes - GRADE assessment ) .There were either no differences for adverse effects or results favoured delayed antibiotics over immediate antibiotics ( low quality evidence - to GRADE assessment ) with no significant differences in complication rates .
For many clinical outcomes , there were no differences between prescribing strategies .
Symptoms for acute otitis media and sore throat were modestly improved by immediate antibiotics compared with delayed antibiotics .
There were no differences in complication rates .
Delayed antibiotics for people with acute respiratory infection  reduced antibiotic use compared to immediate antibiotics , but was not shown to be different to no antibiotics in terms of symptom control and disease complications .
Where clinicians feel it is safe not to prescribe antibiotics immediately for people with respiratory infections , no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use while maintaining similar patient satisfaction and clinical outcomes to delaying prescription of antibiotics .
Where clinicians are not confident in using a no antibiotic strategy , a delayed antibiotics strategy may be an acceptable compromise in place of immediate prescribing to significantly reduce unnecessary antibiotic use for RTIs , and thereby reduce antibiotic resistance , while maintaining patient safety and satisfaction levels .