Objective To assess the overall effect of delayed antibiotic prescribing on average symptom severity for patients with respiratory tract infections in the community, and to identify any factors modifying this effect. Design Systematic review and individual patient data meta-analysis. Data sources Cochrane Central Register of Controlled Trials, Ovid Medline, Ovid Embase, EBSCO CINAHL Plus, and Web of Science. Eligibility criteria for study selection Randomised controlled trials and observational cohort studies in a community setting that allowed comparison between delayed versus no antibiotic prescribing, and delayed versus immediate antibiotic prescribing. Main outcome measures The primary outcome was the average symptom severity two to four days after the initial consultation measured on a seven item scale (ranging from normal to as bad as could be). Secondary outcomes were duration of illness after the initial consultation, complications resulting in admission to hospital or death, reconsultation with the same or worsening illness, and patient satisfaction rated on a Likert scale. Results Data were obtained from nine randomised controlled trials and four observational studies, totalling 55 682 patients. No difference was found in follow-up symptom severity (seven point scale) for delayed versus immediate antibiotics (adjusted mean difference −0.003, 95% confidence interval −0.12 to 0.11) or delayed versus no antibiotics (0.02, −0.11 to 0.15). Symptom duration was slightly longer in those given delayed versus immediate antibiotics (11.4 v 10.9 days), but was similar for delayed versus no antibiotics. Complications resulting in hospital admission or death were lower with delayed versus no antibiotics (odds ratio 0.62, 95% confidence interval 0.30 to 1.27) and delayed versus immediate antibiotics (0.78, 0.53 to 1.13). A significant reduction in reconsultation rates (odds ratio 0.72, 95% confidence interval 0.60 to 0.87) and an increase in patient satisfaction (adjusted mean difference 0.09, 0.06 to 0.11) were observed in delayed versus no antibiotics. The effect of delayed versus immediate antibiotics and delayed versus no antibiotics was not modified by previous duration of illness, fever, comorbidity, or severity of symptoms. Children younger than 5 years had a slightly higher follow-up symptom severity with delayed antibiotics than with immediate antibiotics (adjusted mean difference 0.10, 95% confidence interval 0.03 to 0.18), but no increased severity was found in the older age group. Conclusions Delayed antibiotic prescribing is a safe and effective strategy for most patients, including those in higher risk subgroups. Delayed prescribing was associated with similar symptom duration as no antibiotic prescribing and is unlikely to lead to poorer symptom control than immediate antibiotic prescribing. Delayed prescribing could reduce reconsultation rates and is unlikely to be associated with an increase in symptoms or illness duration, except in young children. Study registration PROSPERO CRD42018079400.

中文翻译：

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呼吸道感染延迟抗生素处方：个体患者数据荟萃分析

目的 评估延迟抗生素处方对社区呼吸道感染患者平均症状严重程度的总体影响，并确定改变这种影响的任何因素。设计系统回顾和个体患者数据荟萃分析。数据来源 Cochrane Central Register of Controlled Trials、Ovid Medline、Ovid Embase、EBSCO CINAHL Plus 和 Web of Science。研究选择的资格标准 在社区环境中进行随机对照试验和观察性队列研究，可以对延迟与不开抗生素处方以及延迟与立即开抗生素处方进行比较。主要结果指标 主要结果是初次咨询后两到四天的平均症状严重程度，按七项量表（从正常到最差）进行测量。次要结局是初次咨询后的病程、导致入院或死亡的并发症、病情相同或恶化的复诊以及按李克特量表评估的患者满意度。结果 数据来自 9 项随机对照试验和 4 项观察性研究，总计 55 682 名患者。延迟使用抗生素与立即使用抗生素（调整后平均差 -0.003，95% 置信区间 -0.12 至 0.11）或延迟使用抗生素与不使用抗生素（0.02，-0.11 至 0.15）的随访症状严重程度（七分制）没有差异。延迟使用抗生素的症状持续时间比立即使用抗生素的症状持续时间稍长（11.4 天 vs 10.9 天），但延迟使用抗生素的症状持续时间与不使用抗生素的症状持续时间相似。延迟使用抗生素与不使用抗生素相比，导致入院或死亡的并发症较低（比值比 0.62，95% 置信区间 0.30 至 1.27），延迟使用抗生素与立即使用抗生素相比（0.78、0.53 至 1.13）。延迟使用抗生素与不使用抗生素相比，复诊率显着降低（比值比 0.72，95% 置信区间 0.60 至 0.87），患者满意度提高（调整后平均差 0.09、0.06 至 0.11）。延迟使用抗生素与立即使用抗生素以及延迟使用抗生素与不使用抗生素的效果不会因既往病程、发烧、合并症或症状严重程度而改变。5 岁以下儿童延迟使用抗生素后的随访症状严重程度略高于立即使用抗生素（调整平均差 0.10，95% 置信区间 0.03 至 0.18），但在年龄较大的组中未发现严重程度增加。结论 对于大多数患者（包括高危亚组患者）来说，延迟抗生素处方是一种安全有效的策略。延迟处方与不处方抗生素的症状持续时间相似，并且不太可能导致比立即处方抗生素更差的症状控制。延迟处方可能会降低复诊率，并且不太可能与症状或病程的增加相关，除幼儿外。研究注册 PROSPERO CRD42018079400。