Noting the public health threat of antibiotic resistance, and the role antibiotics play in medication-related adverse events, physicians associated with the ACP and CDC have issued guidelines on the appropriate use of antibiotics for patients that present with respiratory tract infections.
"Acute respiratory tract infection (ARTI), which includes acute uncomplicated bronchitis, pharyngitis, rhinosinusitis, and the common cold, is the most common reason for acute outpatient physician office visits and antibiotic prescription in adults." Aaron M. Harris, MD, MPH, an internist and epidemiologist with the CDC, and colleagues wrote. "Antibiotics are prescribed at more than 100 million adult ambulatory care visits annually, and 41% of these prescriptions are for respiratory conditions."
The researchers conducted a literature review of evidence-based articles identified using from PubMed, MEDLINE, EMBASE, the Cochrane Library and various professional societies. They presented their findings for four ARTI syndromes as well as prescribing strategies.
Bronchitis and pharyngitis
Harris and colleagues stated that physicians should not perform testing or prescribe antibiotics for patients with uncomplicated bronchitis unless pneumonia is suspected.
"Acute bronchitis is among the most common adult outpatient diagnoses, with about 100 million (10%) ambulatory care visits in the United States per year, more than 70% of which result in a prescription for antibiotics," they wrote. "Acute bronchitis leads to more inappropriate antibiotic prescribing than any other ARTI syndrome in adults."
The researchers recommended the use of cough suppressants, expectorants, first-generation antihistamines, decongestants and beta agonists for symptom relief.
For patients with sore throats, only those with confirmed group A streptococcal pharyngitis should receive antibiotics.
"It is a common outpatient condition, with about 12 million visits representing 1% to 2% of all ambulatory care visits in the United States annually," Harris and colleagues wrote. "Although antibiotics are usually unnecessary, they are prescribed at most visits for pharyngitis."
Patients who present with symptoms such as anterior cervical adenitis, tonsillopharyngeal exudates and persistent fevers should be tested by rapid antigen detection or culture for group A Streptococcus and treated appropriately. Patients with pharyngitis should use analgesic therapies to help minimize pain and receive reassurance that antibiotics are not necessary, as "they do little to alleviate symptoms and may have adverse effects."
Sinusitis and the common cold
Harris and colleagues recommended that physicians manage patients with sinus infections by using supportive care, analgesics, antipyretics and additional therapies such as decongestants, intranasal corticosteroids and antihistamines.
"More than 4.3 million adults are diagnosed with sinusitis annually, and more than 80% of ambulatory care visits result in an antibiotic prescription, most commonly a macrolide," the researchers wrote. "Most antibiotic prescriptions for this condition are unnecessary."
Treatment with antibiotics should be reserved for patients who present with acute rhinosinusitis and who have persistent symptoms for more than 10 days, nasal discharge or facial pain that lasts at least 3 consecutive days and signs of high fever or onset of severe symptoms, or "onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening)," they stated.
Additionally, researchers urged providers not to prescribe antibiotics for patients with the common cold, as they are not effective and increase the risk for adverse effects.
"There are about 37 million (3%) ambulatory care visits each year for the common cold, and roughly 30% result in an antibiotic prescription," they noted.
These patients should be managed with symptomatic therapy, including antihistamines, analgesics and decongestants.
The paper also offered evidence-based strategies designed to help physicians promote appropriate antibiotic prescription, acknowledging that many doctors worry patient satisfaction and patient pressure will affect any interventions. The authors suggested that physicians can use labels such as 'chest cold' or 'viral upper respiratory infection' instead of acute bronchitis. They can also provide patients with informational sheets that address antibiotic use and alternatives that can help manage symptoms.
"A recent study showed an 85% decrease in antibiotic prescribing for ARTI and increased satisfaction ratings when providers gave advice on symptomatic therapy and explained why antibiotics were not needed for ARTI," Harris and colleagues wrote. "A symptomatic prescription pad can be used to provide recommendations for management of symptoms, allowing patients to walk away with a plan of action. When it is unclear whether an antibiotic is needed, delayed or postdated antibiotic prescriptions (also known as the wait-and-see approach) offer the possibility of future antibiotic treatment if the condition does not improve."
ACP president Wayne J. Riley, MD, MPH, MBA, MACP, underscored the importance in following the new guidelines.
“Inappropriate use of antibiotics for ARTIs is an important factor contributing to the spread of antibiotic-resistant infections, which is a public health threat,” he said in the release. “Reducing overuse of antibiotics for ARTIs in adults is a clinical priority and a High Value Care way to improve quality of care, lower health care costs, and slow and/or prevent the continued rise in antibiotic resistance.”
The organizations noted that the guidelines serve as an update to the 2001 Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Infections in Adults and complement to pediatric guidelines published in 2013. – by Chelsea Frajerman Pardes
Disclosures: Development of the guidelines was funded by the ACP and CDC. Please see the full study for a list of the authors’ relevant financial disclosures.