PRINCIPLES OF
APPROPRIATE ANTIBIOTIC USE FOR TREATMENT OF ACUTE RESPIRATORY TRACT INFECTIONS
IN ADULTS: BACKGROUND, SPECIFIC AIMS, AND METHODS.
Gonzales R, et al. Ann Emerg
Med 2001 Jun;37(6):690-7.
The need to decrease excess antibiotic use in ambulatory
practice has been fueled by the epidemic increase in antibiotic-resistant
Streptococcus pneumoniae. The majority of antibiotics
prescribed to adults in ambulatory practice in the United States are for acute
sinusitis, acute pharyngitis, acute bronchitis, and
nonspecific upper respiratory tract infections (including the common cold). For
each of these conditions--especially colds, nonspecific upper respiratory tract
infections, and acute bronchitis (for which routine antibiotic treatment is not
recommended)--a large proportion of the antibiotics prescribed are unlikely to
provide clinical benefit to patients. Because decreasing community use of
antibiotics is an important strategy for combating the increase in
community-acquired antibiotic-resistant infections, the Centers for Disease
Control and Prevention convened a panel of physicians representing the
disciplines of internal medicine, family medicine, emergency medicine, and
infectious diseases to develop a series of "Principles of Appropriate
Antibiotic Use for Treatment of Acute Respiratory Tract Infections in
Adults." These principles provide evidence-based recommendations for
evaluation and treatment of adults with acute respiratory illnesses.This
paper describes the background and specific aims of and methods used to develop
these principles. The goal of the principles is to provide clinicians with
practical strategies for limiting antibiotic use to the patients who are most
likely to benefit from it. These principles should be used in conjunction with
effective patient educational campaigns and enhancements to the health care
delivery system that facilitate nonantibiotic
treatment of the conditions in question.
PRINCIPLES OF
APPROPRIATE ANTIBIOTIC USE FOR TREATMENT OF NONSPECIFIC UPPER RESPIRATORY TRACT
INFECTIONS IN ADULTS: BACKGROUND.
Gonzales R, et al. Ann Emerg
Med 2001 Jun;37(6):698-702
The following principles of appropriate antibiotic use
for adults with nonspecific upper respiratory tract infections apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease.
1. The diagnosis of nonspecific upper respiratory tract infection or acute rhinopharyngitis should be used to denote an acute infection that is typically viral in origin and in which
sinus, pharyngeal, and lower airway symptoms, although frequently present, are
not prominent. 2. Antibiotic treatment of adults with nonspecific upper
respiratory tract infection does not enhance illness resolution and is not
recommended. Studies specifically testing the impact of antibiotic treatment on
complications of nonspecific upper respiratory tract infections have not been
performed in adults. Life-threatening complications of upper respiratory tract
infection are rare. 3. Purulent secretions from the nares
or throat (commonly observed in patients with uncomplicated upper respiratory
tract infection) predict neither bacterial infection nor benefit from
antibiotic treatment.
PRINCIPLES OF
APPROPRIATE ANTIBIOTIC USE FOR ACUTE RHINOSINUSITIS IN ADULTS: BACKGROUND.
Hickner JM, et al. Ann Intern
Med 2001 Mar 20;134(6):498-505.
The following principles of appropriate antibiotic use
for adults with acute rhinosinusitis apply to the
diagnosis and treatment of acute maxillary and ethmoid
rhinosinusitis in adults who are not immunocompromised. Most cases of acute rhinosinusitis
diagnosed in ambulatory care are caused by uncomplicated viral upper
respiratory tract infections. Bacterial and viral rhinosinusitis
are difficult to differentiate on clinical grounds. The clinical diagnosis of
acute bacterial rhinosinusitis should be reserved for
patients with rhinosinusitis symptoms lasting 7 days
or more who have maxillary pain or tenderness in the face or teeth (especially
when unilateral) and purulent nasal secretions. Patients with rhinosinusitis symptoms that last less than 7 days are
unlikely to have bacterial infection, although rarely some patients with acute
bacterial rhinosinusitis present with dramatic
symptoms of severe unilateral maxillary pain, swelling, and fever. Sinus
radiography is not recommended for diagnosis in routine cases. Acute rhinosinusitis resolves without antibiotic treatment in
most cases. Symptomatic treatment and reassurance is the preferred initial
management strategy for patients with mild symptoms. Antibiotic therapy should
be reserved for patients with moderately severe symptoms who meet the criteria
for the clinical diagnosis of acute bacterial rhinosinusitis
and for those with severe rhinosinusitis
symptoms—especially those with unilateral facial pain—regardless of duration of
illness. For initial treatment, the most narrow-spectrum agent active against
the likely pathogens, Streptococcus pneumoniae and Haemophilus influenzae, should be
used.
PRINCIPLES OF
APPROPRIATE ANTIBIOTIC USE FOR TREATMENT OF UNCOMPLICATED ACUTE BRONCHITIS:
BACKGROUND.
Gonzales R, et al. Ann Emerg
Med 2001 Jun;37(6):720-7.
The following principles of appropriate antibiotic use
for adults with acute bronchitis apply to immunocompetent
adults without complicating comorbid conditions, such
as chronic lung or heart disease.The evaluation of
adults with an acute cough illness or a presumptive diagnosis of uncomplicated
acute bronchitis 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 radiography is usually not indicated. In patients with cough
lasting 3 weeks or longer, chest radiography may be warranted in the absence of
other known causes. Routine antibiotic treatment of uncomplicated acute
bronchitis is not recommended, regardless of duration of cough. If pertussis infection is suspected (an
unusual circumstance), a diagnostic test should be performed and antimicrobial
therapy initiated. Patient satisfaction with care for acute bronchitis
depends most on physician--patient communication rather than on antibiotic
treatment.
PRINCIPLES OF
APPROPRIATE ANTIBIOTIC USE FOR ACUTE PHARYNGITIS IN ADULTS: BACKGROUND.
Cooper RJ, et al. Ann Emerg Med
2001 Jun;37(6):711-9.
The following principles of appropriate antibiotic use
for adults with acute pharyngitis apply to immunocompetent adults without complicated comorbid conditions, such as chronic lung or heart disease,
and history of rheumatic fever. They do not apply during known outbreaks of
group A streptococcus. 1. Group A
beta-hemolytic streptococcus (GABHS) is the causal agent in approximately 10%
of adult cases of pharyngitis. The large majority of
adults with acute pharyngitis have a self-limited
illness, for which supportive care only is needed. 2. Antibiotic treatment of
adult pharyngitis benefits only those patients with
GABHS infection. All patients with pharyngitis should
be offered appropriate doses of analgesics and antipyretics, as well as other
supportive care. 3. Limit antibiotic prescriptions to patients who are most
likely to have GABHS infection. Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria: history of fever, tonsillar
exudates, no cough, and tender anterior cervical lymphadenopathy
(lymphadenitis). Do not test or treat patients with none or only one of these
criteria, since these patients are unlikely to have GABHS infection. For
patients with two or more criteria the following strategies are appropriate:
(a) Test patients with two, three, or four criteria by using a rapid antigen
test, and limit antibiotic therapy to patients with positive test results; (b)
test patients with two or three criteria by using a rapid antigen test, and
limit antibiotic therapy to patients with positive test results or patients
with four criteria; or (c) do not use any diagnostic tests, and limit
antibiotic therapy to patients with three or four criteria. 4. Throat cultures
are not recommended for the routine primary evaluation of adults with pharyngitis or for confirmation of negative results on
rapid antigen tests when the test sensitivity exceeds 80%. Throat cultures may
be indicated as part of investigations of outbreaks of GABHS disease, for
monitoring the development and spread of antibiotic resistance, or when such
pathogens as gonococcus are being considered. 5. The preferred antibiotic for
treatment of acute GABHS pharyngitis is penicillin, or erythromycin in a penicillin-allergic
patient.