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

Beth Stuart, Alastair D Hay, Paul Little, et al.

Research output: Contribution to journalArticle (Academic Journal)peer-review

3 Citations (Scopus)
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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 meta-analysis of individual patient data from randomised controlled trials (RCTs) and observational cohorts.
Data sources: Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase, EBSCO CINAHL Plus and Web of Science. Eligibility criteria for study selection: RCTs and observational cohort studies in a community setting which allowed comparison between delayed vs. no antibiotic prescribing, and delayed vs. immediate antibiotic prescribing.

Results: We obtained data from 9 RCTs and 4 observational studies, totalling 55,682 patients. There was no difference in follow-up symptom severity (7 point scale) for delayed antibiotics compared to immediate (mean difference (MD): -0.003, 95% CI: -0.12 to 0.11) or no antibiotics (MD: 0.02, 95% CI -0.11 to 0.15). Symptom duration was slightly longer in those given delayed vs. immediate antibiotics (11.4 days compared 10.9 days but similar for delayed vs no antibiotics. There was a significant reduction in re-consultation (OR 0.72; 95% CI 0.60, 0.87) and an increase in patient satisfaction (0.09, 95% CI 0.06 to 0.11) comparing delayed with no antibiotics.

The effect of delayed vs immediate and vs no antibiotics was not modified by prior duration of illness, fever, comorbidity, or severity of symptoms. Children under 5 had a slightly higher follow-up symptom severity with delayed compared to immediate antibiotics (MD: 0.10, 95% CI 0.03 to 0.18) but there was no increased severity in the older age group.

Conclusions: Delayed prescribing is a safe and effective strategy for most patients. Encouraging delayed prescribing as a tool in consultations may reduce re-consultation and is unlikely to be associated with an increase in symptoms or illness duration, except in young children.
Original languageEnglish
Article numbern808
Number of pages16
JournalBMJ
Volume373
DOIs
Publication statusPublished - 28 Apr 2021

Bibliographical note

Funding Information:
1Academic Unit of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK 2Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK 3Iberoamerican Cochrane Centre, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau-CIBERESP), Barcelona, Spain 4Institute of General Practice, Rostock University Medical Center, Rostock, Germany 5Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand 6Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK 7Division of Health and Social Care Research, King’s College London, London, UK 8Basel Institute for Clinical Epidemiology and Biostatistics (CEB), University Hospital Basel and University of Basel, Switzerland 9Pediatric Emergency Medicine, State University of New York Downstate, Brooklyn, New York, USA 10Institut Català de la Salut, CAP Doctor Carles Ribas, Foc 112, Barcelona, Spain 11Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, UK 12Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK 13Department of Pediatrics, University of Texas Medical Branch at Galveston, Galveston, TX, USA 14Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Barcelona, Spain 15Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain 16ASPIRE PPI Panel, Leeds Institute for Health Sciences, University of Leeds, Leeds, UK We thank the following collaborators who allowed us to use the data from their studies: Professor Ngaire Kerse, Ms Jacqueline Nuttall. Contributors: BS and HH contributed equally to this paper. BS is the guarantor. BS conceived the original study concept and design. BS, PL, MM, SZ, GY, DB, JB, KS, and HCB wrote the grant application and obtained funding from the National Institute for Health Research (NIHR) Research for Patient Benefit (RfPB) Programme. TB, HH, BS, DB, and HCB contributed to the data analysis. BS, HH, and TB wrote the first draft of the manuscript. All listed authors contributed to the

Funding Information:
concept and design of the study, the interpretation of the results, and manuscript editing. All authors read, provided feedback, and approved the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. Funding: This work was funded by the NIHR Research for Patient Benefit (RfPB) Programme (grant No PB-PG-0416-20005). This funding supported the collation of the individual participant data, data management and analyses. The NIHR RfPB was not involved in any other aspect of the project, such as the design of the project’s protocol and analysis plan, the collection and analyses. The funder had no input on the interpretation or publication of the study results.

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