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

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

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.

Anti-Bacterial Agents/therapeutic use, Drug Administration Schedule, Humans, Practice Patterns, Physicians', Respiratory Tract Infections/drug therapy, Time-to-Treatment
0959-8146
Stuart, Beth
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Hounkpatin, Hilda
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Becque, Taeko
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Yao, Guiqing
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Zhu, Shihua
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Alonso-Coello, Pablo
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Altiner, Attila
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Arroll, Bruce
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Böhning, Dankmar
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Bostock, Jennifer
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Bucher, Heiner C.
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Chao, Jennifer
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De La Poza, Mariam
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Francis, Nick
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Gillespie, David
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Hay, Alastair D.
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Kenealy, Timothy
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Löffler, Christin
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McCormick, David P.
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Mas-Dalmau, Gemma
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Muñoz, Laura
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Samuel, Kirsty
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Moore, Michael
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Little, Paul
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Stuart, Beth
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Hounkpatin, Hilda
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Becque, Taeko
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Yao, Guiqing
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Zhu, Shihua
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Alonso-Coello, Pablo
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Altiner, Attila
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Arroll, Bruce
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Böhning, Dankmar
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Bostock, Jennifer
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Bucher, Heiner C.
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Chao, Jennifer
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De La Poza, Mariam
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Francis, Nick
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Gillespie, David
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Hay, Alastair D.
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Kenealy, Timothy
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Löffler, Christin
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McCormick, David P.
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Mas-Dalmau, Gemma
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Muñoz, Laura
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Samuel, Kirsty
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Moore, Michael
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Little, Paul
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Stuart, Beth, Hounkpatin, Hilda, Becque, Taeko, Yao, Guiqing, Zhu, Shihua, Alonso-Coello, Pablo, Altiner, Attila, Arroll, Bruce, Böhning, Dankmar, Bostock, Jennifer, Bucher, Heiner C., Chao, Jennifer, De La Poza, Mariam, Francis, Nick, Gillespie, David, Hay, Alastair D., Kenealy, Timothy, Löffler, Christin, McCormick, David P., Mas-Dalmau, Gemma, Muñoz, Laura, Samuel, Kirsty, Moore, Michael and Little, Paul (2021) Delayed antibiotic prescribing for respiratory tract infections: Individual patient data meta-analysis. The BMJ, 373, [n808]. (doi:10.1136/bmj.n808).

Record type: Article

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.

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More information

Published date: 28 April 2021
Additional Information: 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.
Keywords: Anti-Bacterial Agents/therapeutic use, Drug Administration Schedule, Humans, Practice Patterns, Physicians', Respiratory Tract Infections/drug therapy, Time-to-Treatment

Identifiers

Local EPrints ID: 449570
URI: http://eprints.soton.ac.uk/id/eprint/449570
ISSN: 0959-8146
PURE UUID: e309f5d4-6353-4971-8116-b501941b9ffc
ORCID for Beth Stuart: ORCID iD orcid.org/0000-0001-5432-7437
ORCID for Taeko Becque: ORCID iD orcid.org/0000-0002-0362-3794
ORCID for Dankmar Böhning: ORCID iD orcid.org/0000-0003-0638-7106
ORCID for Nick Francis: ORCID iD orcid.org/0000-0001-8939-7312
ORCID for Michael Moore: ORCID iD orcid.org/0000-0002-5127-4509

Catalogue record

Date deposited: 08 Jun 2021 16:31
Last modified: 28 Apr 2022 02:28

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Contributors

Author: Beth Stuart ORCID iD
Author: Taeko Becque ORCID iD
Author: Guiqing Yao
Author: Shihua Zhu
Author: Pablo Alonso-Coello
Author: Attila Altiner
Author: Bruce Arroll
Author: Jennifer Bostock
Author: Heiner C. Bucher
Author: Jennifer Chao
Author: Mariam De La Poza
Author: Nick Francis ORCID iD
Author: David Gillespie
Author: Alastair D. Hay
Author: Timothy Kenealy
Author: Christin Löffler
Author: David P. McCormick
Author: Gemma Mas-Dalmau
Author: Laura Muñoz
Author: Kirsty Samuel
Author: Michael Moore ORCID iD
Author: Paul Little

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