Delayed antibiotic prescribing effective for most RTI Patients, Finds study

The burden of antimicrobial resistance has increased substantially in recent years. Reducing unnecessary and inappropriate use of antibiotics is crucial to reduce antimicrobial resistance, particularly in primary care where antibiotics are most prescribed.

However, antibiotics are commonly used to treat acute respiratory tract infections, despite studies showing that antibiotics have, at best, modest effects. Guidelines recommend that the fewest number of antibiotic courses should be prescribed for the shortest period possible.

Delayed antibiotic prescribing is a useful strategy that can be used to help reduce antibiotic use, especially during consultations when patients expect to receive an antibiotic prescription.

Hence, Beth Stuart and colleagues from the Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK conducted the study to assess the overall effect of delayed antibiotic prescribing on average symptom severity for patients with respiratory tract infections in the community, and to identify any factors modifying this effect.

The authors carried out randomized controlled trials and observational cohort studies in a community setting that allowed comparison between delayed versus no antibiotic prescribing and delayed versus immediate antibiotic prescribing.

The primary outcome was the average symptom severity two to four days after the initial consultation measured on a seven- item scale (ranging from normal to as bad as could be). Secondary outcomes were duration of illness after the initial consultation, complications resulting in admission to hospital or death, re-consultation with the same or worsening illness, and patient satisfaction rated on a Likert scale.

The following results were highlighted-

1. Data were obtained from nine randomised controlled trials and four observational studies, totalling 55 682 patients.
2. No difference was found in follow-up symptom severity (seven point scale) for delayed versus immediate antibiotics (adjusted mean difference −0.003, 95% confidence interval −0.12 to 0.11) or delayed versus no antibiotics (0.02, −0.11 to 0.15).
3. Symptom duration was slightly longer in those given delayed versus immediate antibiotics (11.4 v 10.9 days), but was similar for delayed versus no antibiotics.
4. Complications resulting in hospital admission or death were lower with delayed versus no antibiotics (odds ratio 0.62, 95% confidence interval 0.30 to 1.27) and delayed versus immediate antibiotics (0.78, 0.53 to 1.13).
5. A significant reduction in reconsultation rates (odds ratio 0.72, 95% confidence interval 0.60 to 0.87) and an increase in patient satisfaction (adjusted mean difference 0.09, 0.06 to 0.11) were observed in delayed versus no antibiotics.
6. The effect of delayed versus immediate antibiotics and delayed versus no antibiotics was not modified by previous duration of illness, fever, comorbidity, or severity of symptoms.
7. Children younger than 5 years had a slightly higher follow-up symptom severity with delayed antibiotics than with immediate antibiotics (adjusted mean difference 0.10, 95% confidence interval 0.03 to 0.18), but no increased severity was found in the older age group.

Therefore, the authors concluded that "delayed antibiotic prescribing is a safe and effective strategy for most patients, including those in higher risk subgroups. Delayed prescribing was associated with similar symptom duration as no antibiotic prescribing and is unlikely to lead to poorer symptom control than immediate antibiotic prescribing."

They further inferred that delayed prescribing could reduce re-consultation rates and is unlikely to be associated with an increase in symptoms or illness duration, except in young children.