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Delayed antibiotic prescription for lower respiratory tract infections

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The impact of different antibiotic prescribing strategies for lower respiratory tract infections (RTIs) in people aged over 16 years has been assessed in a new prospective cohort study.1 Antibiotics continue to be commonly prescribed for RTIs, despite repeated advice to GPs to curb prescriptions owing to lack of efficacy and concerns over resistance. Possible reasons include GPs’ reluctance to antagonise patients, patients’ unrealistic expectations about time to resolution of cough symptoms and GPs’ concerns about distinguishing between a self-limiting RTI and the early manifestations of more dangerous diseases.2

The new study assessed 28,883 UK patients with lower RTIs. Of these, 25.5% were not prescribed antibiotics 61.3% were given a prescription for immediate antibiotics and 13.3% received a prescription for delayed antibiotics. The main outcome measures were reconsultation with symptoms of lower RTI within 30 days of the index consultation, hospital admission and death. After exclusion of 104 (0.4%) patients (referred to hospital for radiographic investigation or admission or both at index consultation, or admitted with cancer), hospital admission or death occurred in 26 out of 7,332 (0.3%) patients with no antibiotic prescription, 156 out of 17,628 (0.9%) patients prescribed immediate antibiotics and 14 out of 3,819 (0.4%) with a prescription for delayed antibiotics.

Multivariable analysis showed no significant reductions in hospital admission or death with immediate antibiotics (multivariable risk ratio [MRR] 1.06, 95% CI 0.63 to 1.81) or with delayed antibiotics (MRR 0.81, 95% CI 0.41 to 1.64). Reconsultation for new, worsening or non-resolving symptoms was significantly reduced by delayed antibiotics (MRR 0.64, 95% CI 0.57 to 0.72) but not by immediate antibiotics (MRR 0.98, 95% CI 0.90 to 1.07).

(The research was funded by the National Institute for Health Research.)

Comment: This study highlights the scale of antibiotic prescribing in primary care for people with lower respiratory tract infections, with almost 75% receiving a prescription. However, it provides some reassurance that a strategy of prescribing delayed antibiotics is a reasonable approach for young people and adults with an uncomplicated lower respiratory tract infection. It supports national initiatives to promote use of delayed prescriptions as part of antibiotic stewardship.3,4


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