BACKGROUND AND PURPOSE:

• Stuart et al. (BMJ, 2021) assessed the impact of delayed antibiotic prescribing as a strategy to reduce unnecessary antibiotic use among patients presenting with respiratory tract infections

METHODS:

• Systematic review and individual patient data meta-analysis
• Data sources
  • Cochrane Central Register of Controlled Trials | Ovid Medline | Ovid Embase | EBSCO CINAHL Plus | Web of Science
• Inclusion criteria
  • RCTs and observational cohort studies
  • Community setting
  • Studies that compared either
    • Delayed vs no antibiotic prescribing
    • Delayed vs immediate antibiotic prescribing
• Delayed prescribing
  • Antibiotic prescribed but patient advised to only use if condition worsens or does not improve after a specified time period or
  • “Watchful waiting approach” where patient is observed prior to prescription
• Primary outcome
  • Average symptom severity 2 to 4 days after initial consultation
    • Measured on a scale (ranging from ‘normal’ to ‘as bad as could be’)
• Secondary outcomes
  • Duration of illness after the initial consultation
  • Complications resulting in admission to hospital or death
  • Reconsultation with the same or worsening illness
  • Patient satisfaction

RESULTS:

• 9 RCTs | 4 observational studies | 55,682 total patients
• No difference in follow-up symptom severity for
  • Delayed vs immediate antibiotics
    • Adjusted mean difference (AMD) −0.003 (95% CI, −0.12 to 0.11)
  • Delayed vs no antibiotics
    • AMD 0.02 (95% CI, −0.11 to 0.15)
• Symptom duration was slightly longer in those given delayed vs immediate antibiotics
  • Delayed: 11.4 days
  • Immediate: 10.9 days
  • Hazard ratio 1.04 (95% CI, 1.01 to 1.08)
• Symptom duration was similar for delayed vs no antibiotics
• Complications resulting in hospital admission or death were lower in delayed group but not statistically significant  
  • Delayed vs immediate antibiotics
    • Odds ratio (OR) 0.78 (95% CI, 0.53 to 1.13)
  • Delayed vs no antibiotics
    • OR 0.62 (95% CI, 0.30 to 1.27)
• Delayed vs no antibiotics showed a significant
  • Reduction in reconsultation rates
    • OR 0.72 (95% CI, 0.60 to 0.87)
  • Increase in patient satisfaction
    • AMD 0.09 (95% CI, 0.06 to 0.11)
• The effect of delayed vs immediate antibiotics or no antibiotics was not modified by
  • Previous duration of illness
  • Fever
  • Comorbidity
  • Severity of symptoms
• Children <5 years had a slightly higher follow-up symptom severity with delayed antibiotics than with immediate antibiotics
  • AMD 0.10 (95% CI, 0.03 to 0.18)

CONCLUSION:

• Delayed antibiotic prescribing was associated with similar symptom duration compared to no antibiotics among patients with respiratory infections
• Young children under 5 experienced higher symptom severity when antibiotic prescribing was delayed
• The authors conclude

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

Learn More – Primary Sources:

Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis

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