Fresh analysis supports delayed antibiotic prescribing in respiratory care in the community

Here, patients agree not to collect a prescription immediately, opting to wait and see if their symptoms improve as part of campaign to reduce a reliance on antibiotics.

The results show that delayed prescribing and no antibiotic prescribing was associated with a similar duration of symptoms. It was unlikely to lead to poorer symptom control when compared to immediate antibiotic prescribing, the authors suggest.

While prescribing immediate antibiotics had a slight benefit for children, the authors did not consider this to be important enough to justify prescribing antibiotics immediately.

Chance to 'resolve expectations?'

In general, people recover from respiratory tract infections without treatment, but in many countries, including the UK, antibiotics are still prescribed routinely for conditions such as sore throats, coughs and ear infections. In their conclusions, the team airs the view that their findings might help clinicians and patients resolve ‘mismatched expectations’ over prescribing habits.

The team assessed the effect of delayed antibiotic prescribing on symptoms for patients with respiratory tract infections in the community, using individual patient data from nine randomised controlled trials and four observational studies (involving a total of 55,682 patients).

They compared average symptom severity between delayed versus no antibiotic prescribing, and delayed versus immediate antibiotic prescribing.

Primary care settings

Most studies were conducted in primary care settings and the average age of study participants ranged from 2.7 to 51.7 years. The team took factors such as patient age, gender, previous duration of illness, severity of symptoms, smoking status and underlying conditions into account.

Average symptom severity was measured two to four days after the initial consultation on a seven-point scale (ranging from normal to as bad as could be). The researchers found no difference in symptom severity for delayed versus immediate antibiotics or delayed versus no antibiotics.

Symptom duration was slightly longer in those given delayed versus immediate antibiotics (11.4 versus 10.9 days) but was similar for delayed versus no antibiotics.

Complications resulting in hospital admission or death were lower with delayed versus no antibiotics and delayed versus immediate antibiotics, but neither result was statistically significant.

Re-consultation rates

A significant reduction in re-consultation rates and an increase in patient satisfaction were found for delayed versus no antibiotics, but not for delayed versus immediate antibiotics.

Delayed prescribing could be used as a standalone interventional approach, but it might also be a way of resolving mismatched expectations between clinician and patient [Beth Stuart and colleagues]

Children younger than five years had a slightly higher symptom severity with delayed antibiotics than with immediate antibiotics, but this was not considered to be clinically meaningful, and no increased severity was found in the older age groups.

The research team took account of differences in study design and quality to minimise bias. However, the article acknowledges there were some limitations and that the results could have been affected by some unmeasured factors.

Conclusions and comparisons

Dr Stuart and her colleagues conclude that delayed antibiotic prescribing ‘delayed prescribing appears to be a safe and effective antibiotic strategy for most patients, including those in higher risk subgroups’.

‘Compared with a no prescription approach, delayed prescribing probably reduces reconsultation rates, and therefore the workload of general practitioners, with slightly higher levels of patient satisfaction.

‘Compared with immediate antibiotics, delayed prescribing does not result in higher complication rates (if anything, they are lower) and it does not significantly decrease patient satisfaction.

‘Delayed prescribing could be used as a standalone interventional approach, but it might also be a way of resolving mismatched expectations between clinician and patient.’

To see the article, titled Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis, visit: https://www.bmj.com/content/373/bmj.n808

Funding: National Institute for Health Research