Clinical Question

In adults with lower respiratory tract infection, what is the effect of different antibiotic prescribing strategies?

Bottom Line

Delayed antibiotic treatment (that is, giving a prescription with a suggestion to fill it only if symptoms are still present after three days) was associated with decreased revisits by adults with new-onset cough deemed to be infective. Neither immediate nor delayed antibiotic treatment altered hospitalization rates, but this lack of difference might be because of appropriately selective prescribing of antibiotics to more at-risk patients. In this study, one in four patients was not prescribed antibiotic treatment and fared as well as the patients who received a prescription. (Level of Evidence = 2b)

Synopsis

This study included adult patients seen in U.K. primary care offices who had acute cough for three weeks or less that was judged by their physician to be due to infection. Follow-up included 99.6% of patients. Of the 28,779 patients not immediately referred for hospitalization or radiographic investigation, 25.5% were not treated with an antibiotic, 61.3% received a prescription for an antibiotic, and 13.3% received a prescription for a delayed antibiotic (average advised delay was three days). This was not a randomized study and physicians were selective in their use of antibiotics, prescribing immediate antibiotics for patients who were older; had major comorbidities; reported more shortness of breath, fever, or purulent sputum; or had low oxygen saturation, more severe cough, and crackles or wheeze. Subsequently, hospitalization or death occurred in 0.3% after no antibiotic, 0.9% after immediate antibiotic treatment, and 0.4% after a delayed antibiotic (no statistically significant difference). Follow-up visits were common in all groups but were significantly reduced by delayed antibiotic treatment (14.1% with a delayed antibiotic vs. 19.7% with no antibiotic and 25.3% with an immediate antibiotic).

Study design: Cohort (prospective)

Funding source: Government

Setting: Outpatient (primary care)

Reference: LittlePStuartBSmithSet alAntibiotic prescription strategies and adverse outcome for uncomplicated lower respiratory tract infections: prospective cough complication cohort (3C) study. BMJ2017;357:j2148.