Delaying Antibiotics May Avoid Side Effects For Kids With Respiratory Infections

Children with acute, uncomplicated respiratory infections have similar symptom duration and severity with immediate antibiotics, delayed antibiotics, or no antibiotics at all, a randomized clinical trial found.

Researchers randomly assigned children with acute uncomplicated respiratory infections at 39 primary care centers to receive an immediate antibiotic prescription (n=148), delayed antibiotics (n=146), or no antibiotic prescription (n=142). The primary endpoint was symptom duration and severity; secondary endpoints included antibiotic usage, parental satisfaction; additional primary care visits; and complications within 30 days.

Mean symptom duration of severe symptoms was 10.1 days with immediate antibiotics, 12.4 days with delayed antibiotics, and 10.9 days without antibiotics. None of the differences was statistically significant, the authors report in Pediatrics.

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Parents rated symptoms on a 7-point scale, ranging from 0 for no problems to 6 for the worst possible symptoms. Median symptom severity was 3 in all three trial arms, and there were no significant differences in the proportion of children with moderate or severe symptoms.

With delayed antibiotics, far fewer children (25.3%) received antibiotics than with immediate antibiotic prescriptions (96%).

Gastrointestinal side effects were more common with immediate antibiotics (8.8%) than delayed antibiotics (3.4%) or with no antibiotic prescription (2.8%).

"Antibiotics are unnecessary in the majority of non-complicated respiratory tract infections in children," said senior study author Pablo Alonso-Coello, a researcher at the Biomedical Research Institute Sant Pau in Barcelona.

"Delayed antibiotic prescription is a strategy for a more rational use of this kind of medication, one that avoids unnecessary adverse effects and also reduces antimicrobial resistance, a major public health crisis we are already facing," Alonso-Coello said by email.

Most parents of children in all three trial arms reported being "very" or "extremely" satisfied with treatment. Researchers didn't find significant differences in repeat visits to primary care, use of non-antibiotic medications, or complications.

There were three unscheduled hospital visits, one perforated eardrum, and one hospitalization due to dehydration.

The study results suggest that antibiotic prescriptions are often unnecessary for this patient population, said Geoffrey Spurling, of the University of Queensland in Brisbane, Australia.

"For uncomplicated respiratory infections in children, avoiding antibiotics is safe and results in high levels of patient satisfaction," Spurling, who wasn't involved in the study, said by email. "For clinicians who are uncomfortable with this approach, a strategy of delayed antibiotics is safe and results in a much lower rate of unnecessary antibiotic use than a strategy of immediate antibiotics."

Clinicians who don't immediately give antibiotics do need to advise parents on how to manage symptoms like fever and pain and stress the importance of hydration, said Dr. Ray O'Connor of the University of Limerick School of Medicine in Ireland.

"Usually if a child is generally well, drinking fluids and passing urine then they are winning the battle," Dr. O'Connor, who wasn't involved in the study, said by email. "If any of these stops then the child is in trouble and parents need to seek advice again."

—Lisa Rapaport

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