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This study reports the likely effect of different strategies of antibiotic prescribing on symptom control and antibiotic use when controlling for commonly used analgesic advice and advice to inhale with steam that could plausibly affect symptom control.

This study was a pragmatic open factorial trial of delayed antibiotic strategies, controlling for symptomatic advice regarding analgesia and steam, with a parallel observational component for patients judged to need immediate antibiotics.

All prescriptions must be issued for a specific patient. The web figure uses an example group (no prescription) to illustrate this randomisation process.During the trial (from January 2011), a strategy of no antibiotic prescription was added as a randomised comparison, bringing the total number of randomised groups to five (fig 1).During the study, it became clear from systematic reviews that delayed prescribing might result in higher antibiotic use than no initial prescription.8 We therefore added a no prescription group to facilitate interpretation of the effect of delayed prescription compared with the alternatives strategies, particularly because both the delayed and no prescription groups in the current study had higher antibiotic use than in previous studies.A statistician independent of the study team coordinated the randomisation using computer generated random numbers.Conclusion Strategies of no prescription or delayed antibiotic prescription result in fewer than 40% of patients using antibiotics, and are associated with less strong beliefs in antibiotics, and similar symptomatic outcomes to immediate prescription.