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Clinical Decisionmaking

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Researchers examine the use of antibiotics to treat acute respiratory infections in otherwise healthy adults

Up to 75 percent of the antibiotics prescribed each year are for upper respiratory tract infections. Yet most of these prescriptions are unnecessary, since most respiratory tract infections are caused by viruses and are unaffected by antibiotics. Unnecessary use of antibiotics contributes to antibiotic-resistant strains of bacteria, which then require even stronger antibiotics to treat.

These antibiotic-resistant bacteria have multiplied to create a situation in the United States in which current antibiotics may soon be ineffective in treating resistant strains of serious illnesses such as bacterial pneumonia or meningitis. Strategies aimed at reducing community use of antibiotics need to address the management of acute respiratory infections.

The Centers for Disease Control and Prevention (CDC) recently convened a panel of physicians—representing the disciplines of internal medicine, family medicine, emergency medicine, and infectious diseases—to develop a series of evidence-based recommendations for appropriate antibiotic use for treatment of acute respiratory tract infections in otherwise healthy adults. The approach taken by the panel of physicians and recommendations for appropriate antibiotic use for uncomplicated bronchitis and pharyngitis are detailed in three position papers, which are described here.

This research was supported in part by the Agency for Healthcare Research and Quality (National Research Service Award fellowship F32 HS00134).

Gonzales, R., Bartlett, J.G., Besser, R.E., and others (2001, March). "Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: Background, specific aims, and methods." Annals of Internal Medicine 134, pp. 479-486.

The recommendations for evaluating and treating otherwise healthy adults with acute respiratory tract infections originated from a review of the pertinent research literature through March 2000 by a multidisciplinary panel of physicians. After analyzing and interpreting the studies, they completed several draft recommendations, which were eventually endorsed by the American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine, CDC, and the Infectious Diseases Society of America. The basic theme of the recommendations is that antibiotics not be routinely prescribed for acute respiratory tract infections in healthy adults.

Recommended practices provide clinicians with practical strategies for limiting antibiotic use to the patients who are most likely to benefit from it. For most healthy adults, the best treatment for bronchitis, sinusitis, pharyngitis (sore throat), and nonspecific upper respiratory tract infections is over-the-counter cold remedies and salt water gargles to relieve symptoms. These principles should be used in conjunction with effective patient education campaigns and enhancements to the health care delivery system that facilitate nonantibiotic treatment of these conditions.

Gonzales, R., Bartlett, J.G., Besser, R.E., and others (2001, March). "Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: Background." Annals of Internal Medicine 134, pp. 521-529.

Uncomplicated acute bronchitis in healthy adults is an acute respiratory tract infection chiefly characterized by a cough with or without phlegm. Evaluation of these adults should focus on ruling out serious illness, particularly pneumonia. In healthy, nonelderly adults, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds, and chest x-rays usually are not indicated. In patients with a cough lasting 3 weeks or longer, chest x-rays may be warranted in the absence of other known causes of the cough, recommend the panel of physicians. They do not recommend routine antibiotic treatment of uncomplicated acute bronchitis, regardless of duration of the cough. If pertussis (whooping cough) infection is suspected (an unusual circumstance), a diagnostic test should be performed and antibiotic therapy initiated.

Patients frequently expect to receive antibiotics for acute bronchitis, but not getting antibiotics is not the important issue. Instead, the doctor spending enough time with them and explaining the illness and treatment plan has a stronger relationship to satisfaction, according to this study. Doctors should provide realistic expectations for the duration of the patient's cough, which will typically last 10 to 14 days after the office visit; refer to the illness as a "chest cold" rather than bronchitis; and personalize the risk of unnecessary antibiotic use. This risk ranges from allergic reactions to the medication to gastrointestinal discomfort, yeast infections, and drug-drug interactions. Doctors also should mention the need for restraint in prescribing antibiotics and the current epidemic of antibiotic resistance. Management of patients with acute bronchitis with underlying chronic obstructive pulmonary disease, congestive heart failure, or compromised immune systems must be tailored in light of these problems.

Snow, V., Mottur-Pilson, C., Cooper, R.J., and others (2001, March). "Principles of appropriate antibiotic use for acute pharyngitis in adults." Annals of Internal Medicine 134, pp. 506-508.

Acute pharyngitis (sore throat) accounts for 1 to 2 percent of all visits to outpatient departments, physician offices, and emergency departments, and viruses are the most common cause. About 5 to 15 percent of adult cases are caused by group A beta-hemolytic streptococcus (GABHS), so-called strep throat. Antibiotics are prescribed to many patients with acute pharyngitis because of perceived patient expectations or physician desire to avoid such potential but rare strep-related complications as rheumatic fever and acute glomerulonephritis (kidney inflammation). However, according to the panel of physicians, doctors should not routinely prescribe antibiotics for healthy adults with acute pharyngitis who have no history of rheumatic fever, valvular heart disease, compromised immune system, or chronic pharyngitis. Instead, doctors should offer these patients analgesics, antipyretics (fever-reducing medications), and other supportive care.

The goal of the diagnostic evaluation should be to predict which patients have a high likelihood of GABHS pharyngitis or strep throat. Unfortunately, the results of throat cultures differ when checked at 24 or 48 hours, and they cannot distinguish acute infection from the carrier state. The panel recommends use of clinical criteria alone or the use of rapid antigen testing as an adjunct to clinical screening. Each strategy is associated with 70 percent or greater sensitivity and specificity and allows treatment decisions to be made early in the course of illness to provide patients with symptom relief.

Doctors should initiate antibiotic treatment of adults who have at least three of four clinical criteria: history of fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough, all of which are associated with GABHS pharyngitis. Another approach is to initiate antibiotic treatment of adults with all four clinical criteria, rapid antigen testing of patients with three (or perhaps two) clinical criteria followed by treatment of those with positive test results, and nontreatment of all others. The preferred antibiotic agent for treatment of acute GABHS pharyngitis is penicillin or erythromycin in penicillin-allergic patients.

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