Spurling Geoffrey K P, Del Mar Chris B, Dooley Liz, Foxlee Ruth, Farley Rebecca
Discipline of General Practice, University of Queensland, Herston, Australia.
Cochrane Database Syst Rev. 2013 Apr 30(4):CD004417. doi: 10.1002/14651858.CD004417.pub4.
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. This is an update of a Cochrane Review originally published in 2007 and updated in 2010.
To evaluate the use of delayed antibiotics compared to immediate or no antibiotics as a prescribing strategy for ARTIs. We evaluated clinical outcomes including duration and severity measures for pain, malaise, fever, cough and rhinorrhoea in sore throat, acute otitis media, bronchitis (cough) and the common cold. We also evaluated the outcomes of antibiotic use, patient satisfaction, antibiotic resistance and re-consultation rates and use of alternative therapies.
We searched CENTRAL (The Cochrane Library 2013, Issue 2), which includes the Acute Respiratory Infection Group's Specialised Register; Ovid MEDLINE (January 1966 to February Week 3 2013); Ovid MEDLINE In-Process & Other Non-Indexed Citations (28 February 2013); EMBASE (1990 to 2013 Week 08); Science Citation Index - Web of Science (2007 to May 2012) and EBSCO CINAHL (1982 to 28 February 2013).
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.
Three review authors independently extracted and collected data. Important adverse effects, including adverse effects of antibiotics and complications of disease, were included as secondary outcomes. We assessed the risk of bias of all included trials. We contacted trial authors to obtain missing information where available.
Ten studies, with a total of 3157 participants, were included in this review. 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 evaluated in 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 antibiotic use compared to immediate antibiotics. A strategy of no antibiotics resulted in least antibiotic use.Patient satisfaction favoured immediate antibiotics over delayed (odds ratio (OR) 0.52; 95% confidence interval (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.None of the included studies evaluated antibiotic resistance.
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.
由于不良反应、成本和抗菌药物耐药性等问题，人们对抗生素用于急性呼吸道感染（ARTIs）的处方存在担忧。减少抗生素处方的一种策略是开具处方，但建议推迟用药，期望症状能先自行缓解。这是对一篇Cochrane系统评价的更新，该评价最初发表于2007年，2010年进行过更新。
评估与立即使用抗生素或不使用抗生素相比，延迟使用抗生素作为ARTIs的处方策略的效果。我们评估了临床结局，包括咽痛、急性中耳炎、支气管炎（咳嗽）和普通感冒中疼痛、不适、发热、咳嗽和流涕的持续时间及严重程度指标。我们还评估了抗生素使用的结局、患者满意度、抗生素耐药性、再次就诊率以及替代疗法的使用情况。
我们检索了CENTRAL（《Cochrane图书馆》2013年第2期），其中包括急性呼吸道感染组的专业注册库；Ovid MEDLINE（1966年1月至2013年2月第3周）；Ovid MEDLINE在研及其他未索引引文（2013年2月28日）；EMBASE（1990年至2013年第8周）；科学引文索引 - 科学网（2007年至2012年5月）以及EBSCO CINAHL（1982年至2013年2月28日）。
随机对照试验（RCTs），涉及所有年龄段被定义为患有ARTIs的参与者，将延迟使用抗生素与立即使用抗生素或不使用抗生素进行比较。
三位综述作者独立提取和收集数据。重要的不良反应，包括抗生素的不良反应和疾病的并发症，被纳入次要结局。我们评估了所有纳入试验的偏倚风险。我们联系试验作者以获取可用的缺失信息。
本综述纳入了10项研究，共3157名参与者。10项纳入研究及其结果的异质性通常排除了进行荟萃分析的可能性，但患者满意度除外。在咳嗽和普通感冒中评估的临床结局方面，延迟、立即和未开具抗生素之间没有差异。在一些研究中，对于急性中耳炎（AOM）和咽痛患者，立即使用抗生素在发热、疼痛和不适方面比延迟使用更有效。不良反应仅有微小差异，并发症发生率无显著差异。与立即使用抗生素相比，延迟使用抗生素导致抗生素使用显著减少。不使用抗生素的策略导致抗生素使用最少。患者满意度方面，立即使用抗生素优于延迟使用（比值比（OR）0.52；95%置信区间（CI）0.35至0.76）。延迟使用和不使用抗生素的满意度相似，两种策略的满意度均超过80%（OR 1.44；95%CI 0.99至2.10）。立即使用和延迟使用组的再次就诊率没有差异。纳入的研究均未评估抗生素耐药性。
大多数临床结局在不同策略之间没有差异。与立即使用抗生素相比，延迟使用抗生素会使患者满意度略有降低（87%对92%），但与不使用抗生素相比则无差异（87%对83%）。在临床医生认为立即不开具抗生素是安全的呼吸道感染患者中，不使用抗生素并建议如果症状未缓解则复诊，可能会导致抗生素使用最少，同时保持与延迟使用抗生素相似的患者满意度和临床结局。
