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Am Fam Physician. 2021;104(3):online

Clinical Question

What is the effect of a delayed-prescription approach for children with respiratory tract infection?

Bottom Line

A strategy of providing education about the natural history of respiratory symptoms in children combined with giving a take-and-hold prescription (to be filled only if symptoms persisted) resulted in one in four of those children eventually receiving an antibiotic. However, it increased the number of children who used other medications to control symptoms, which indicates the parents' need to do something. Symptom severity and time to resolution, complications, and follow-up visits were similar whether children received immediate, delayed, or no antibiotic treatment. Immediate treatment resulted in more gastrointestinal symptoms. Similar results have been shown in adults. (Level of Evidence = 1b)


The investigators enrolled 436 children from 39 primary care centers. The children were between two and 14 years of age (most were 10 years or younger) and had pharyngitis, rhinosinusitis, acute bronchitis, or acute otitis media for which the treating pediatrician had reasonable doubts about the need to prescribe an antibiotic. Pediatricians who had access to rapid streptococcal testing did not include children with pharyngitis in this study. The children were randomly assigned using concealed allocation to receive no antibiotic treatment, a prescription for an antibiotic to be started immediately, or a prescription to be started only if the patient had a fever or felt much worse after 24 hours, or if the child did not start to feel better after four, seven, 15, or 20 days from symptom onset for acute otitis media, pharyngitis, rhinosinusitis, or acute bronchitis, respectively. All parents were told that it was normal for a child to feel slightly worse in the first days after a visit and the natural history of the respective condition was described (e.g., the cough of acute bronchitis could last for 20 days). Almost all (96%) of the children in the immediate antibiotic group received treatment, whereas only 25% of the delayed group and 12% in the no antibiotic group received an antibiotic. Symptoms took an average of eight days to disappear, regardless of treatment group. The duration of days with severe symptoms was similar in both groups. Nonantibiotic symptom treatment was more common in the delayed or no antibiotic group compared with the immediate treatment group (P < .001). Complications and unscheduled visits were similar across the groups. Gastrointestinal symptoms were higher with immediate treatment. Satisfaction was similar among all three groups.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (primary care)

Reference: Mas-Dalmau G, Villanueva López C, Gorrotxategi Gorrotxategi P, et al.; DAP PEDIATRICS GROUP. Delayed antibiotic prescription for children with respiratory infections: a randomized trial. Pediatrics. 2021;147(3):e20201323.

Editor's Note: Dr. Shaughnessy is an assistant medical editor for AFP.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

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