Most respiratory illnesses don’t require antibiotics, which can have harmful side effects.
Should you take antibiotics for a simple respiratory infection?
The Centers for Disease Control and Prevention recommends that health care personnel prescribe antibiotics sparingly, for many reasons. First, the overuse of the drugs leads to the development of resistant strains of bacteria, a growing problem that is reducing the effectiveness of all antibiotics. The drugs can also have serious side effects, ranging from mild rashes or diarrhea to less common and severe allergic reactions.
Because antibiotics can destroy normally helpful bacteria in the gut, their use can lead to life-threatening intestinal infections with Clostridioides difficile, or C. diff. The use of antibiotics in infancy and childhood has been linked to the development of allergic and autoimmune diseases, probably because they disturb the body’s normal balance of microorganisms. According to one estimate, adverse reactions to antibiotics result in 143,000 emergency room visits annually.
For all these reasons, most doctors have been trying to limit antibiotic use. For doctors and their professional organizations, “antibiotic stewardship” has become the watchword.
In some cases, the C.D.C. recommends an approach called “delayed prescribing.” With this approach, the doctor gives a patient a prescription for antibiotics, with instructions to wait a few days to fill it, and see if they get better without medicine. There is good evidence that this procedure is safe and effective for otitis media, a common ear infection, and for the nasal congestion of sinusitis.
Now a new review of studies, published in BMJ, suggests that delayed prescribing may also be a safe and effective approach for treating most respiratory tract infections. For their analysis, researchers combined individual patient data on more than 55,000 people in nine randomized controlled trials and four observational studies.
On average, they found no difference in follow-up on a seven-point symptom severity scale between patients given immediate antibiotics for respiratory infections and those given delayed prescriptions.
Those who got delayed prescriptions had symptoms for an average 11.4 days, about the same as those given no antibiotics at all, compared with 10.9 days for those given the drugs immediately. Patients who got delayed prescriptions were less likely to visit the doctor again, and were more satisfied with their treatment than those given no prescription.
In children younger than 5, symptoms were slightly more severe during follow-up in those given a delayed prescription rather than immediate antibiotics.
“A lot of these symptoms clear up in a few days anyway,” said the lead author, Beth Stuart, an associate professor at the University of Southampton in England. “So on average, antibiotics don’t have a huge benefit.”
“But what about special cases where antibiotics can be useful? Is delayed prescribing safe for them too?” she said. “Yes. It’s safe and effective to send them off with a delayed prescription and instructions about what to look for.”
But Dr. Jeffrey A. Linder, a professor of medicine at Northwestern who was not involved in the research, urged caution, noting that the data the researchers used did not properly distinguish diagnoses. “The most likely interpretation of the finding that there is no difference in symptom duration between patients who received immediate antibiotics, delayed antibiotics and no antibiotics,” he said, “is that most of these patients did not need antibiotics in the first place.”
The authors took measures to statistically account for differences between the various illnesses, he continued, but the study “mixes up clinical conditions that should be treated with antibiotics — strep throat, otitis media — with those that should not be — colds, acute bronchitis, viral pharyngitis.”
Dr. Holly M. Frost, an assistant professor of pediatrics at Denver Health who was not involved in the study, added that in real-world practice, few doctors use delayed prescriptions, even in cases where it is already recommended, much less for respiratory infections. “Almost everyone with ear infections and sinusitis is getting antibiotics,” she said.
Moreover, delayed prescriptions may not help with reducing antibiotic use, she said, since most people just go directly to the pharmacy with their “delayed” prescription anyway. In one medical practice she surveyed, she found that 93 percent of delayed prescriptions were filled immediately.
Lecturing patients about antibiotic resistance, she said, is not the right approach either. Rather, the approach should be, “You’re not going to feel any better if you take antibiotics.” She is not against the practice of offering delayed prescriptions, but sees it as one option among several.
“We have to explore any strategies we have for reducing antibiotic prescribing,” she said.
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