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#53 Advantages and limitations of ‘delayed prescriptions’ of antibiotics for upper respiratory tract infections (URTI)


CLINICAL QUESTION
What are the advantages and limitations of ‘delayed prescriptions’ of antibiotics for upper respiratory tract infections (URTI)?


BOTTOM LINE
Delayed antibiotic prescriptions substantially reduce antibiotic use but may slightly worsen some symptoms compared with immediate prescriptions. Delayed prescriptions may also reduce return to care rates and for mild URTI, are not associated with important negative consequences.



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EVIDENCE
 A ‘delayed antibiotic prescription’ involves advice to fill prescription only if necessary. 
  • Cochrane systematic review:1 
    • Nine randomized controlled trials (RCTs) compared delayed to immediate antibiotic:  
      • Filled antibiotic prescriptions: 32% in delayed group versus 93% in immediate.  
      • Outcomes of delayed versus immediate (statistically significant differences reported): 
        • Bronchitis or common cold: No difference. 
        • Pharyngitis: Two studies found fever severity at day three worse with delayed but other outcomes not different.  
        • Otitis media: One study found pain severity and malaise at day three worse with delayed but other outcomes not different. 
        • Delayed slightly reduced patient satisfaction (87% versus 92%). 
      • In one study, return-to-care rate lower with delayed. 
      • Adverse events: Two studies found reduced diarrhea in delayed group; other studies showed no differences. 
  • New RCTs 
    • In patients previously prescribed antibiotics for cough, delayed prescriptions reduced return-to-care rates.2 
    • No difference among four different methods of delayed prescriptions in symptom severity, duration, return-to-care rates or patient satisfaction.3 
      • Antibiotic use: 26% in no antibiotic group and 37% in delayed. 
Context:   
  • Other systematic review had similar findings.4,5  
  • Concerns with antibiotics included: 
    • May promote resistant bacteria in the user and in the population.6,7 
    • Frequent side effects (e.g. rash, diarrhea).8  
  • Three RCTs compared delayed antibiotic to no antibiotic1 
    • 14% in no-antibiotic group filled an antibiotic prescription versus 32% in delayed group. 
  • Delayed prescriptions are not appropriate when patients: 
    • Present with worse symptoms9 (for example, in children with otitis mediathose with fever or vomiting did worse with delayed antibiotics).10 
    • Have important comorbidities (e.g. heart failure).9 
    • Have barriers to accessing follow up care. 


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Author(s):

  • Bruce Arroll MBChB PhD FRNZCGP
  • G. Michael Allan MD CCFP
  • Noah Ivers MD CCFP

1. Spurling GK, Del Mar CB, Dooley L, et al. Cochrane Database Syst Rev. 2013; 4:CD004417.

2. Moore M, Little P, Rumsby K, et al. Br J Gen Pract. 2009 Oct; 59(567):728-34.

3. Little P, Moore M, Kelly J, et al. BMJ. 2014; 348:g1606.

4. Andrews T, Thompson M, Buckley DI, et al. PLoS One. 2012;7(1):e30334.

5. Arroll B, Kenealy T, Kerse N. Br J Gen Pract. 2003 Nov; 53(496):871-7.

6. Arason VA, Kristinsson KG, Sigurdsson JA, et al. BMJ. 1996; 313:387-91.

7. Venkatesan P, Innes JA. Thorax. 1995; 50:481-3.

8. Berman S, Byrns PJ, Bondy J, et al. Pediatrics 1997; 100(4):585-92.

9. NICE Clinical Guideline 69. London: National Institute for Health and Clinical Excellence, July 2008. http://www.nice.org.uk/Guidance/cg69 (accessed 19 May 2015).

10. Little P, Gould C, Moore M, et al. BMJ. 2002 Jul 6; 325(7354):22.

Authors do not have any conflicts of interest to declare.