Delayed antibiotics for symptoms and complications of acute respiratory tract infections

Previous reviews indicate that antibiotics have, at best, only modest benefit for acute respiratory tract infections (ARTIs). These benefits need to be balanced against adverse effects, costs and the risk of bacteria becoming resistant to antibiotics. One way for doctors to reduce their use is to prescribe delayed antibiotics (meaning providing the prescription but advising the patient/carer to delay their use in the hope that symptoms resolve first). Delayed prescribing resulted in 32% of patients using antibiotics compared to 93% of patients in the immediate prescription group. However, not prescribing antibiotics at all results in the least antibiotic prescribing (14% of patients used antibiotics).

This review found 10 studies, involving 3157 participants, looking at prescribing strategies for respiratory infections. It was generally not possible to combine results from different studies because of incomplete information from some studies and the different types of patients in each study. There were only three trials comparing the strategies of delayed and no antibiotics.

For most symptoms like fever, pain and malaise, there was no difference between immediate, delayed and no antibiotics. The only differences were small and favoured immediate antibiotics for relieving pain and fever for sore throat and pain and malaise for middle ear infections. There was little difference in adverse effects of antibiotics for the three prescribing strategies and no significant difference in complication rates.

Patient satisfaction was slightly reduced in the delayed antibiotic group (87% satisfied) compared to the immediate antibiotic group (92% satisfied). Satisfaction rates were similar between delayed and no antibiotic groups (83% satisfied).

No included studies evaluated antibiotic resistance.

When doctors feel it is safe not to prescribe antibiotics immediately, prescribing none with advice to return if symptoms do not resolve rather than delaying them will result in lower subsequent antibiotic use, while maintaining similar patient satisfaction and symptom outcomes.

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.

Read the full abstract...

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.

Search strategy: 

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).

Selection criteria: 

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.

Data collection and analysis: 

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.

Main results: 

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.