Delayed antibiotics for respiratory infections

 

Abstract

Background

Concerns exist regarding antibiotic prescribing for acute respiratory tract infections (ARTIs) owing to adverse reactions, cost and antibacterial resistance. One strategy to reduce antibiotic prescribing is to provide prescriptions, but to advise delay in the hope symptoms will resolve first.

Objectives

To evaluate clinical outcomes, adverse effects, antibiotic use and patient satisfaction associated with delayed antibiotic prescribing compared to immediate prescribing or no antibiotics for ARTIs.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 1), which contains the Acute Respiratory Infections Group's Specialised Register; MEDLINE (January 1966 to March Week 3 2009), EMBASE (1990 to 2009 Week 12), CINAHL (1982 to March Week 4 2009); Current Contents (1998 to December 2007) and Science Citation Index (2007 to March 2009).

Selection criteria

Randomised controlled trials (RCTs) involving participants of all ages defined as having an ARTI, where delayed antibiotics were compared to antibiotics used immediately or no antibiotics.

Data collection and analysis

Data were collected and analysed by three review authors.

Main results

Heterogeneity of the 10 included studies and their results generally precluded meta-analysis with patient satisfaction being an exception.

There was no difference between delayed, immediate and no prescribed antibiotics for the clinical outcomes cough and common cold. In patients with acute otitis media (AOM) and sore throat immediate antibiotics were more effective than delayed for fever, pain and malaise in some studies. There were only minor differences in adverse effects with no significant difference in complication rates.

Delayed antibiotics resulted in a significant reduction in antibiotics compared to immediate antibiotics. A strategy of no antibiotics resulted in least antibiotic use.

Patient satisfaction favoured immediate antibiotics over delayed (OR 0.52; 95% CI 0.35 to 0.76). Delayed and no antibiotics had similar satisfaction rates with both strategies achieving over 80% satisfaction (OR 1.44; 95% CI 0.99 to 2.10).

There was no difference in re-consultation rates for immediate and delayed groups.

Authors' conclusions

Most clinical outcomes show no difference between strategies. Delay slightly reduces patient satisfaction compared to immediate antibiotics (87% versus 92%), but not compared to none (87% versus 83%). In patients with respiratory infections where clinicians feel it is safe not to prescribe antibiotics immediately, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use, while maintaining similar patient satisfaction and clinical outcomes to delayed antibiotics.

 

Plain language summary

Delayed antibiotics for symptoms and complications of acute respiratory tract infections

Previous reviews indicate that antibiotics have, at best, only modest benefit for acute respiratory tract infections (ARTIs). These benefits need to be balanced against adverse effects, costs, and the risk of bacteria becoming resistant to antibiotics. One way for doctors to reduce the use of antibiotics is to prescribe delayed, (meaning providing the prescription, but advising the patient/carer to delay their use in the hope that symptoms resolve first). Delayed prescribing resulted in 32% of patients using antibiotics compared to 93% of patients in the immediate prescription group. However, not prescribing antibiotics at all results in the least antibiotic prescribing (14% of patients used antibiotics).

While this review found 10 studies looking at prescribing strategies for respiratory infections, it was generally not possible to combine results from different studies because of incomplete information from some studies and the different types of patients in each study. There were only three trials comparing the strategies of delayed and no antibiotics.

For most symptoms like fever, pain and malaise, there was no difference between immediate, delayed and no antibiotics. The only differences were small and favoured immediate antibiotics for relieving pain and fever for sore throat and pain and malaise for middle ear infections. There was little difference in adverse effects of antibiotics for the three prescribing strategies and no significant difference in complication rates.

Patient satisfaction was slightly reduced in the delayed antibiotic group (87% satisfied) compared to the immediate antibiotic group (92% satisfied). Satisfaction rates were similar between delayed and no antibiotic groups (83% satisfied).

When doctors feel it is safe not to prescribe antibiotics immediately, prescribing none with advice to return if symptoms do not resolve rather than delaying them will result in lower subsequent antibiotic use, while maintaining similar patient satisfaction and symptom outcomes.

 

摘要

背景

延遲使用抗生素治療呼吸道感染

以抗生素治療急性上呼吸道感染的些許好處，必須權衡其常見的副作用、成本和細菌抗藥性。減少抗生素處方的方法是引人關注的課題。策略之一是先提供處方簽，但建議患者48小時之後才能使用，希望這段時間內症狀會自己緩解。主張這種方法的人認為這樣可以使患者對治療的滿意度較好。這篇文獻回顧主要觀察延遲使用抗生素對於呼吸道感染之臨床療效、抗生素之使用以及對病人的滿意度之影響為何。

目標

評估在急性呼吸道感染時，延遲使用抗生素和立即使用抗生素或沒有使用抗生素在臨床療效，抗生素之使用及病人滿意度之比較。

搜尋策略

我們搜尋Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 1)，其中包括Acute Respiratory Infections Group's Specialised Register、MEDLINE (January 1966 to March Week3 2009)、EMBASE (1990 to 2009 Week 12)、CINAHL (1982 to March Week 4 2009)、Current Contents (1998 to December2007)及Science Citation Index (2007 to March 2009)。

選擇標準

對所有年齡層之急性呼吸道感染患者，比較延遲使用抗生素和立即使用抗生素或沒有使用抗生素的隨機對照研究(RCTs)。評量之結果包含臨床療效，是否使用抗生素以及病人之滿意度。

資料收集與分析

數據之收集和分析由三位作者完成。

主要結論

由於被納入分析的10篇研究及其結果的異質性(Heterogeneity)，統合分析(metaanalysis)基本上不大適用，除了在病患滿意度這一項的分析上。延遲使用抗生素組、立即使用抗生素組或沒有使用抗生素組在咳嗽及一般感冒等臨床結果上並無差別。一些研究發現急性中耳炎和喉嚨痛的患者，立即使用抗生素組較延遲使用抗生素組對發燒、疼痛和倦怠的療效較佳，在副作用的部分有些微差異，但是在併發症上則沒有明顯差別。延遲使用抗生素組較立即使用抗生素組可明顯減少抗生素的使用。不使用抗生素的策略造成了最少的抗生素使用。在病患滿意度上立即使用抗生素組較延遲使用抗生素組高(OR 0.52; 95% CI 0.35 to0.76)。延遲使用抗生素組與沒有使用抗生素組的病患滿意度則差不多，皆可達80% 以上(OR 1.44; 95% CI 0.99 to 2.10)。至於病患的再回診比例，立即使用或延遲使用抗生素兩組間並無差別。

作者結論

抗生素之使用方式對大多數之臨床結果沒有影響。延遲使用抗生素相較於立即使用抗生素，在病人的滿意度方面稍差(87% versus 92%)，但與沒有使用抗生素相比則無差別(87% versus 83%)。當病人有呼吸道感染，而醫師覺得不處方抗生素是安全的時候，給予病人如果症狀未改善再回來門診的醫囑而不直接開立抗生素，可能可以讓抗生素的使用量減至最低，同時臨床上之效果及病人之滿意度卻可達到與延遲使用抗生素差不多的水準。

翻譯人

本摘要由慈濟醫院謝至鎠翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

過去的研究指出，在急性上呼吸道感染時使用抗生素只有些許好處，並需要同時權衡其副作用、花費和產生抗藥性細菌的風險。讓醫生減少抗生素使用的方式之一就是開立〝延遲使用的抗生素〞(指提供處方，但建議患者或照顧者不要太早使用，以期待症狀先自己緩解)。延遲使用抗生素組中使用抗生素之比例為32%，而立即使用組則為93%。然而，未處方抗生素組使用抗生素之比例才是最低(有14%的病患使用過抗生素)。雖然此篇對於呼吸道感染處方抗生素的文獻回顧包含10篇不同的研究，但由於某些研究資料不完整或是各研究中病人的形態不同，我們無法將這些研究的結果綜合分析。其中只有3篇是比較延遲使用及不使用抗生素的研究。立即、延遲或不使用抗生素對於大部分的症狀，包括發燒、疼痛及倦怠的治療效果沒有差異。唯有些許差異來自於立即使用抗生素組對喉嚨痛患者的發燒和疼痛，以及對中耳炎患者的疼痛和倦怠症狀的療效稍佳。三種處方抗生素的方法，在副作用有些許差異，但是在併發症發生率上並無差別。相較於立即使用抗生素組，延遲使用抗生素組在病人的滿意度方面稍差(87% versus 92%)，但與沒有使用抗生素組相比則差不多(87% versus 83%)。當醫師覺得，不立即處方抗生素是安全時，只給予病人“如果症狀未改善再回來門診”的醫囑而不直接開立抗生素，可以降低抗生素的使用量，同時臨床結果及病人之滿意度並不會變得較差。