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

Abstract

Objective 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. Design Systematic review and individual patient data meta-analysis. Data sources Cochrane Central Register of Controlled Trials, Ovid Medline, Ovid Embase, EBSCO CINAHL Plus, and Web of Science. Eligibility criteria for study selection Randomised 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. Main outcome measures 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, reconsultation with the same or worsening illness, and patient satisfaction rated on a Likert scale. Results Data were obtained from nine randomised controlled trials and four observational studies, totalling 55 682 patients. 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). 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. 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). 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. 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. 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. Conclusions 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. Delayed prescribing could reduce reconsultation rates and is unlikely to be associated with an increase in symptoms or illness duration, except in young children. Study registration PROSPERO CRD42018079400.

How can general practitioners reduce antibiotic prescribing in collaboration with their patients?

“…Delayed prescribing has been successfully used in primary care to reduce antibiotic prescribing for respiratory 25 and urinary infections 26 and bacterial conjunctivitis, 27 and it is a safe strategy for most patients, including higher risk subgroups. 28 In a recent systematic review and individual patient meta-analysis from nine randomised controlled trials and four observational studies, 28 complications resulting in hospitalisation or death were lower with delayed prescribing when compared with no antibiotics (odds ratio [OR]: 0.62; 95% confidence interval [CI]: 0.30, 1.27) or immediate antibiotics (OR: 0.78; 95% CI: 0.53, 1.13). Patients who received a delayed prescription were more satisfied than those who received no antibiotics at the end of the consultation, 25 and with a significant reduction in consultation rates (OR: 0.72; 95% CI: 0.60, 0.87).…”

“…Patients who received a delayed prescription were more satisfied than those who received no antibiotics at the end of the consultation, 25 and with a significant reduction in consultation rates (OR: 0.72; 95% CI: 0.60, 0.87). 28 Thus, delayed prescribing may be a preferable strategy to simply denying antibiotics, especially when consulting with challenging patients. Delayed prescribing and safety netting is discussed further in the article in this issue by Magin et al 29…”

Antibiotic stewardship: A review of successful, evidence-based primary care strategies

“…Delayed prescribing of antibiotics is probably the single simplest and most effective strategy, as only approximately one-third of patients given a delayed script end up using it. 26 For patients who do not need an antibiotic, such as those with a simple viral URTI or uncomplicated bronchitis, an information handout provides a useful alternative 'prescription' that also reduces antibiotic usage.…”

Delayed antibiotic prescribing for respiratory tract infections with and without sepsis—a dilemma or not?

“…After analysing data from 13 community based studies involving 55 682 patients, Stuart and colleagues conclude that “delayed antibiotic prescribing is a safe and effective strategy for most patients” with respiratory tract infections 1…”