Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. Respiratory infections are one of the commonest reasons for patients to present to primary care or general practice, and antibiotics are widely used as a treatment for them. However, there are increasing concerns about the use of antibiotics and various strategies have been developed to reduce their use. These include something called 'delayed antibiotics' and, in October 2023, the relevant Cochrane Review was updated. Here's Geoff Spurling from the University of Queensland in Australia to tell us about this strategy and the latest findings of the review.

Geoff: The delayed antibiotic strategy was developed in response to the vexing problem of antibiotic overuse, especially for respiratory infections, where it is known that antibiotics are usually not recommended. However, prescribing doctors either don't know this or feel pressured by patients to prescribe. This is despite delayed antibiotics having been shown to be one of the most effective strategies for reducing unnecessary antibiotic prescriptions for respiratory infections. Unnecessary antibiotics are costly, risk side effects and contribute to antibiotic resistance and we wanted to bring together the evidence from randomised trials to quantify the effects of immediate versus delayed versus no antibiotics for respiratory infections.
For this update, we found and included one extra randomised trial, so our findings are now based on 12 trials involving almost 4000 participants and a good mix of adults and children. This shows that if a doctor provides an immediate prescription for antibiotics then, on average, 93% of these will be filled. Whereas, if a doctor provides a prescription with instructions to delay starting the antibiotics, then only 29% of people will go and get the antibiotics from a pharmacy. Lastly, if the doctor does not issue a prescription, 13% of people will go elsewhere to obtain and fill a prescription for antibiotics, showing that the idea that people will just go "down the road" for an antibiotic prescription if the first doctor does not provide one, rarely happens. Similarly, all three strategies have high patient satisfaction levels, of above 80%, although satisfaction is slightly higher for delayed antibiotics than for no antibiotics.
In regard to clinical outcomes, most of these were similar across the three groups with some small benefits for immediate antibiotics in some trials for symptom improvement. However, there were also fewer adverse effects of antibiotics in the delayed and no antibiotic groups, as one might expect.
In summary, the take home message for GPs is that when they feel it is safe not to prescribe antibiotics immediately, but don't feel confident saying no to the patient, then a delayed antibiotic prescription will result in a greatly reduced quantity of antibiotics being taken while maintaining patient satisfaction and not compromising patient safety.

Mike: If you'd like to find out more about the delayed antibiotic strategy and its benefits, you can read the latest version of Geoff's review by going online to Cochrane Library dot com. If you type 'delayed antibiotics' into the search box, you'll see a link to it.