Delayed antibiotic prescribing: safe and effective for most patients with respiratory infection

By Nicole MacKee
A wait­-and­-see approach to antibiotic prescribing is a ‘safe and effective strategy for most patients’ with respiratory tract infections, researchers have reported in The BMJ.

A systematic review and meta-­analysis of the individual data of more than 55,000 patients from nine randomised controlled trials and four observational studies compared delayed antibiotic prescribing with both immediate and no antibiotic prescribing.

A delayed antibiotic prescribing strategy – where patients were given a prescription for an antibiotic but advised not to start the course unless their condition deteriorated or failed to improve – could help to address antimicrobial resistance, the researchers said.

The researchers found no difference in symptom severity (two to four days after initial consultation) between delayed prescribing compared with immediate or no antibiotics. Only in children aged under 5 years was symptom severity found to be greater when delayed antibiotic prescribing was compared with immediate prescribing.

Symptom duration was slightly longer when delayed prescribing was compared with immediate prescribing, but was similar when compared with no antibiotics.

Delayed prescribing resulted in fewer hospitalisations when compared with immediate and no antibiotics. And, when compared with no antibiotics, delayed prescribing also resulted in greater patient satisfaction and a significant reduction in reconsultation rates.

Consistent results were found in higher risk subgroups, such as patients with lung comorbidities.

The researchers pointed to previous research papers that had suggested that delayed prescribing, compared with immediate prescribing, could cut antibiotic use by 23 to 75%.

Professor Chris Del Mar, Professor of Public Health at Bond University and an expert in respiratory viruses, said some Australian GPs have used delayed prescribing ‘for years’, but others were reluctant.

He said this evidence would be helpful in reassuring more GPs about the safety of a ‘wait­-and­-see approach’.

‘There were no clinically important adverse effects from this strategy (return visits to the GP, a serious infection or hospital admissions),’ Professor Del Mar said.

‘However, GPs are often reluctant to use delayed prescribing even when they think antibiotics are not necessary, worrying that a wait­-and­-see approach risks disaster. This evidence, which was very well conducted, is likely to reassure GPs who are reluctant. The strategy is likely to join the several initiatives designed to reduce prescribing.’

This was important, Professor Del Mar said, noting that Australian GPs were one of the highest prescribers of antibiotics in the developed world.

‘Delayed prescribing is effective at reducing antibiotic use, it improves patient satisfaction compared to a “no prescribing” approach, and is safe,’ he said.
BMJ 2021; 372: n808;