Date of this Version


Document Type

Journal Article

Publication Details

Spurling GKP, Del Mar CB, Dooley L, Foxlee R. Delayed antibiotics for symptoms and complications of respiratory infections. The Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004417. DOI: 10.1002/14651858.CD004417.pub2.
This review is published as a Cochrane Review in The Cochrane Library 2006, Issue 2.
This version first published online: 18 October 2004 in Issue 4, 2004.
Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and The Cochrane Library should be consulted for the most recent version of the Review.
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Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.


Background: Providing patients with a prescription for antibiotics but suggesting delaying their use is a strategy that reduces antibiotic use. This review asks what effect this practice has on the clinical course of the illness.

Objectives: To evaluate the clinical effect of delayed antibiotic use in acute upper respiratory tract infections compared to immediate use of antibiotics.

Search strategy: The following electronic databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (January 1966 to January Week 1 2004), EMBASE (1990 to September 2003) and Current Contents (1998 to 2003).

Selection criteria: Clinical outcomes measured included fever, cough, pain, malaise, complications of disease, adverse effects from antibiotics. Trial quality and data extraction were assessed independently by two reviewers blinded to author and journal for each study.

Data collection and analysis: Data were analysed and reported using Review Manager.

Main results: Seven randomised controlled trials (RCTs) were of high quality. Missing data and marked heterogeneity prevented meta-analysis. Three studies out of six reported fever, all for sore throat, showed more fever in the delayed antibiotic group. The remaining three showed no difference. There was no symptom differences for patients with cough or the common cold. Pain and malaise severity scores at day three significantly favoured the immediate antibiotic group in children with acute otitis media (Little 2001).

El-Daher 1991 showed reduced vomiting in children in the immediate antibiotic group with suspected streptococcal pharyngitis but there was no difference in children with sore throat in Little 1997. Little 1997 and Arroll 2002a showed no difference for the outcome of diarrhoea, while Little 2001 reported less diarrhoea in the delayed antibiotic group in children with otitis media.

Authors' conclusions: Delayed antibiotics have been used in an attempt to reduce the use of antibiotic prescriptions. For most outcomes there is no difference between immediate and delayed antibiotic groups. Three of the six studies, indicated that patients in the delayed antibiotic group had significantly more fever. Pain and malaise scores were worse for children with otitis media in the delayed antibiotic group. This price must be weighed up against the benefits of reduced antibiotic prescribing. Future RCTs of delaying antibiotics should fully report symptoms as well as changes of prescription rates.

Plain language summary: Previous studies have indicated that antibiotics have at best modest benefit for upper respiratory tract infections, which needs to be balanced against adverse effects and the risk of bacteria becoming resistant to antibiotics

Doctors prescribe delayed antibiotics to reduce the consumption of antibiotics while attempting to maintain patient satisfaction. This review looks at the effect of this strategy on the course of the illness in people with upper respiratory tract infections. It found that patients in three out of six studies, all with sore throat, had more fever if they delayed antibiotics. Additionally, children with a middle ear infection had more pain and malaise if they delayed antibiotics. For patients with cough or the common cold there was no difference between delayed and immediate antibiotic groups.



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