Delayed antibiotic prescribing in respiratory tract infections: is it an effective and safe strategy for children?

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Aim: Delayed prescriptions can be used for antibiotics in cases when immediate initiation of treatment is not indicated. The patient is provided with instructions when to commence the antibiotic course in association with their symptoms. The method is employed in primary care and some emergency departments, aiming at reducing unnecessary antibiotic use. We evaluated the efficacy and the safety of delayed antibiotic prescribing in the paediatric population

Methods: We searched for randomised controlled trials (RCTs) comparing delayed antibiotic prescribing with immediate or no prescription for respiratory tract infections in children (3 months to 16 years). The relevant Cochrane review and National Institute for Health and Care Excellence (NICE) guideline were used as sources to identify primary studies. We extracted paediatric data from RCTs that included a mixed population of children and adults. A primary literature search was conducted for new studies (from March 2013 to September 2017). MEDLINE and EMBASE were searched using relevant keywords. Cochrane risk of bias tool was used to assess the methodological quality of the included studies

Results: 11 RCTs with a total population of 2,172 children, were included in the analysis. 7 trials conducted exclusively in a paediatric population. 5 RCTs investigated delayed antibiotics in acute otitis media (AOM), 4 in sore throat and one in cough (acute bronchitis). One trial included patients with different types of acute respiratory tract infections. Delayed antibiotics, when compared with immediate antibiotics, reduce the antibiotic use in children [3 studies, RR: 0.46, 95%CI(0.27 to 0.78)] (Figure 1). Immediate antibiotics decrease the duration of symptoms by maximum one day. In one study, delayed antibiotics were associated with increased rate of treatment failure in children below 2 years of age with AOM [RR: 3.90, 95%CI(1.34, 11.37)]. All included studies either did not consider safety in their outcome measures or were not powered to detect differences.

Conclusions: There is evidence that delayed antibiotics are effective in reducing antibiotic use in children. However, the safety of this strategy remains largely unknown and further research is required. Clinicians should use delayed antibiotics in children with caution and especially in children younger than 2 years.