Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis
BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n808 (Published 28 April 2021) Cite this as: BMJ 2021;373:n808Read our latest coverage of the coronavirus pandemic
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Dear Editor
Thank you, Stuart et al., for sharing such good article.
According to Patel et al. (2023), it has been shown that every national, regional, and global has different NAPs in antimicrobial stewardship. There is a linkage between following SOP and rapid diagnosis. Even in developed countries (like Australia) has gap for improvement. Therefore, overall, the article covers different numbers of countries, only one article from 1991 describes the situation in low- and middle-income country, so further investigation is needed to determine whether delaying prescriptions would affect the reconsultation rates or severity of diseases in these countries. This deeper exploration is necessary to achieve advancements in reducing antibiotic prescribing and enhancing patient safety.
*Patel, J., Harant, A., Fernandes, G., Mwamelo, A. J., Hein, W., Dekker, D., & Sridhar, D. (2023). Measuring the global response to antimicrobial resistance, 2020–21: a systematic governance analysis of 114 countries. The Lancet Infectious Diseases.
Competing interests: No competing interests
Dear Editor
We thank Dr Bradley for his thoughts. As Dr Bradley suggests, there is no evidence that early treatment of suspected sepsis in primary care improves outcomes. Indeed, the key challenge in primary care is the timely identification of early sepsis, which can be indistinguishable from common infections early on. Observational data suggest that the risk of sepsis in RTI is lower than in other conditions and the number needed to treat is large. Following RTI in the age group 65–74 years, the NNT was 1,257 (1,112–1,434) in men and 2,278 (1,966–2,686) in women [1].
Nevertheless, fear amongst clinicians that if a patient develops a serious illness there might be actual or perceived blame is prevalent, and an important driver of immediate antibiotic prescribing.
Approaches to managing this problem must therefore acknowledge uncertainty, and primary care clinicians need to be ready to support each other in recognising that not all sepsis, or other adverse outcomes, can be ‘detected early’ or prevented. Prescribing immediate antibiotics to all patients with RTI to try and prevent a rare adverse outcome would result in dramatically overtreating and over-medicalising and an increase in antibiotic resistance. This would almost certainly harm more people than it benefits.
It is clearly important for clinicians to have a low threshold for detecting the uncommon symptoms and signs that point towards a diagnosis of sepsis. Providing patients with a safety net by giving them information about symptoms that should prompt them to get further help is also an essential component for achieving timely treatment of sepsis. However, these approaches are equally important regardless of whether the treatment strategy is immediate, no or delayed antibiotics.
1. Gulliford MC, Charlton J, Winter JR, Sun X, Rezel-Potts E, et al. (2020) Probability of sepsis after infection consultations in primary care in the United Kingdom in 2002–2017: Population-based cohort study and decision analytic model. PLOS Medicine 17(7): e1003202. https://doi.org/10.1371/journal.pmed.1003202
Competing interests: No competing interests
Dear Editor
Great read.
FYI there is an error in the abstract. The results for symptom severity mean difference for delayed versus no antibiotics AND delayed versus immediate antibiotics are swapped.
Cheers
Competing interests: No competing interests
Dear Editor
Stuart et al., after analysing data from 13 community-based studies involving 55,682 patients concluded that “delayed antibiotic prescribing is a safe and effective strategy for most patients” with respiratory tract infections (1).
However, it is widely held that antibiotic treatment within the first hour reduces mortality in patients with infections complicated by sepsis - although this is increasingly being questioned as none of the few prospective or randomised trials have demonstrated a benefit (2).
The problem, particularly in a primary care setting, is that pneumonia is largely impossible to diagnose clinically according to blinded prospective studies (3,4), and even in an intensive care setting sepsis is also difficult to identify according to other studies (5,6).
This creates a dilemma particularly for the primary care physician. If a patient presents with respiratory symptoms and antibiotics are not prescribed and the patient subsequently dies from pneumonia and sepsis, then the physician could be deemed negligent despite the uncertainty that optimum treatment would have altered the outcome and despite the fact that the majority of deaths occur in the elderly with frailty and comorbidities (2).
1. Stuart B, Hounkpatin H, Becque T, et al. Delayed antibiotic prescribing for respiratory tract infections: individual patient meta-analysis. BMJ 2012;373:n808.
2. Singer M, Inada-Kim M, Shankar-Hari M. Sepsis hysteria; excess hype and unrealistic expectations. The Lancet 2019;394:1513-4.
3. Metlay J, Wishna K, Fine M. Does This Patient Have Community-Acquired Pneumonia? Diagnosing Pneumonia by History and Physical Examination. JAMA 1997;278(17):1440-5.
4. Wipf J, Lipsky B, Hirschmann J, et al. Diagnosing pneumonia by physical examination: relevant or relic?. Arch Intern Med 1999;159(10)1082-7.
5. Dremsizov T, Clermont G, Kellum J, et al. Severe Sepsis in Community-Acquired Pneumonia. When Does it Happen, and do Systemic Inflammatory Response Criteria Help Predict course? CHEST 2006;129:968-78.
6. Rhee C, Kadri S, Danner R, et al. Diagnosing sepsis is subjective and highly variable: a survey of intensivists using case vignettes. Crit Care 2016;20:89.
Competing interests: No competing interests
Re: Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis
Thank you, Stuart et al., for sharing such good article.
According to Patel et al. (2023), it has been shown that every national, regional, and global has different NAPs in antimicrobial stewardship. There is a linkage between following SOP and rapid diagnosis. Even in developed countries (like Australia) has gap for improvement. Therefore, overall, the article covers different numbers of countries, only one article from 1991 describes the situation in low- and middle-income country, so further investigation is needed to determine whether delaying prescriptions would affect the reconsultation rates or severity of diseases in these countries. This deeper exploration is necessary to achieve advancements in reducing antibiotic prescribing and enhancing patient safety.
*Patel, J., Harant, A., Fernandes, G., Mwamelo, A. J., Hein, W., Dekker, D., & Sridhar, D. (2023). Measuring the global response to antimicrobial resistance, 2020–21: a systematic governance analysis of 114 countries. The Lancet Infectious Diseases.
Competing interests: No competing interests