Delayed therapy

Delayed therapy (observation) may be an option in nonsevere cases. Bl... 

Tsakonas E, Fitzgerald AA, Fitzcharles MA, et al. Consequences of delayed therapy with second-line agents in rheumatoid arthritis A 3 year followup on the hydroxychloroquine in early rheumatoid arthritis (HERA) study. J Rheumatol 2000 27 623-629. 

It is difficult to identify who wiU benefit from antimicrobial therapy. With or without treatment, about 60% of children who have acute otitis media are symptom-free within 24 hours. In almost 40% of the remaining children, antibiotic use reduces the duration of symptoms by about 1 day. A trial of 315 children (6 months to 10 years of age) compared immediate antibiotic treatment with a 72-hour delay in treatment that was to be given only if the child had not improved. Symptoms continued for 1 extra day in 10% to 20% of the delayed-therapy group, but 10% fewer also experienced diarrhea. At 3 days, there was no difference in symptoms. In the delayed-therapy group, only 24% of children evenmally received antibiotics, and 77% of parents reported being satisfied with this approach. ... 

If delayed therapy is tried, nse of appropriate pain medication, snch as oral ibnprofen or acetaminophen, shonld be advised. If a child 6 months to 2 years of age does not improve by 24 honrs or an older child by 72 hours, antibiotic treatment should be initiated. ... 

In addition to the desire for immediate symptom improvement, prevention of mastoiditis and meningitis has been suggested as a reason to prescribe immediate antibiotic treatment for acute otitis media. The rates of mastoiditis in the Netherlands, Norway, and Denmark (all countries in which delayed therapy has been adopted) and those in Canada, the United States, Austraha, and the United Kingdom were compared. The delay of antibiotic use resulted in an increase from about 2 to 4 cases of mastoiditis per 100,000 children per year, accompanied by about 1600 fewer children per 100,000 experiencing antibiotic side effects. Of note, in the Netherlands, only 1.1% of infections caused by S. pneumoniae are penicUhn-resistant. 

The management of chronic lymphocytic leukemia (CLL) is highly variable and may include delaying therapy in asymptomatic older patients, well-tolerated single-agent chemotherapy in symptomatic older patients, and more aggressive therapy in younger patients. 

Table 2. Effect of delaying therapy (IV atropine, pralidoxime, diazepam) on protection ratios in guinea pigs given pyridostigmine 30 min before nerve agent (Green et al., 1983)...

No scientifically validated test substantiates the diagnosis of multiple chemical sensitivities. The diagnosis of multiple chemical sensitivities may perpetuate illness, prolong disability, and delay therapy (Sparks et al. 1994b). 

To delay therapy until laboratory results are available is inappropriate in serious bacterial infections, but specimens for possible microbial identification must be obtained before drugs are administered. The answer is (B). 

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