Southampton, UK—Delayed antibiotic prescribing is one way to control the use of  valuable drugs, but until now, it wasn’t clear the technique was safe and effective with respiratory tract infections.

With delayed antibiotic prescribing—also called ‘just in case prescribing’—patients agree not to fill a prescription immediately but to wait and see if symptoms improve first.

An analysis in the BMJ suggests that delayed prescribing was associated with a duration of symptoms similar to that of no antibiotic prescribing and is unlikely to lead to worse outcomes than immediate antibiotic prescribing. A slight benefit for children with immediate antibiotics was indicated but wasn’t significant, according to United Kingdom researchers from the University of Southampton and colleagues.

Overprescribing of antibiotics is a problem particularly in respiratory tract infections, which affect the sinuses, throat, airways, or lungs and include conditions such as the common cold, sore throat, cough, and ear infection, according to the authors. Even though most patients get better without treatment, too many physicians prescribe immediate antibiotics.

One alternative is delayed antibiotic prescribing for respiratory tract infections, and past clinical trials have suggested that is likely safe and effective for most patients. Those studies were limited, however, prompting the current meta-analysis.

The systematic review searched for 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. Defined as the primary outcome was the average symptom severity 2 to 4 days after the initial consultation measured on a seven-item scale (ranging from normal to as bad as could be). Researchers also looked at secondary outcomes, including duration of illness after the initial consultation, complications resulting in admission to hospital or death, reconsultation with the same or worsening illness, and patient satisfaction rated on a Likert scale.

Ultimately, data were obtained from nine randomized, controlled trials and four observational studies involving a total of 55,682 patients.

Results indicate no difference in follow-up symptom severity for delayed versus immediate antibiotics (adjusted mean difference −0.003, 95% CI, −0.12- 0.11) or delayed versus no antibiotics (0.02, 95% CI, −0.11- 0.15).

While symptom duration was slightly longer in those given delayed versus immediate antibiotics (11.4 vs. 10.9 days), it was similar for delayed versus no antibiotics. On the other hand, the authors report, complications resulting in hospital admission or death were lower with delayed versus no antibiotics (odds ratio 0.62, 95% CI, 0.30- 1.27) and delayed versus immediate antibiotics (0.78, 95% CI, 0.53- 1.13).

“A significant reduction in reconsultation rates (odds ratio 0.72, 95% CI, 0.60- 0.87) and an increase in patient satisfaction (adjusted mean difference 0.09, 95% CI, 0.06- 0.11) were observed in delayed versus no antibiotics,” according to the researchers, who add that the effect of delayed versus immediate antibiotics and delayed versus no antibiotics did not seem to be affected by previous duration of illness, fever, comorbidity, or severity of symptoms.

They advise, however, that children younger than age 5 years had a slightly higher follow-up symptom severity with delayed antibiotics than with immediate antibiotics (adjusted mean difference 0.10, 95% CI, 0.03- 0.18), but no increased severity was found in the older age group.

“Delayed antibiotic prescribing is a safe and effective strategy for most patients, including those in higher risk subgroups,” the authors conclude. “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. Delayed prescribing could reduce reconsultation rates and is unlikely to be associated with an increase in symptoms or illness duration, except in young children.”

The authors suggest that 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.”

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