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Know when not to prescribe
In an effort to stop injudicious use of antibiotics in outpatient settings, the Centers for Disease Control and Prevention and clinical colleagues recently issued new guidelines. In addition to CDC participation, the recommendations were developed in conjunction with a panel of physicians representing internal medicine, family medicine, emergency medicine, and infectious diseases.
The guidelines apply only to immunocompetent adults with no important comorbid conditions, such as pulmonary or cardiac disease. The targeted clinical setting is outpatient practice, but the guidelines can also apply to residents of long-term care facilities (if they fit the patient inclusion criteria). The recommendations are summarized as follows:
Nonspecific upper-respiratory tract infection
Recommendation 1. The diagnosis of nonspecific upper respiratory tract infection should be used to denote an acute infection in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent. These infections are predominantly viral in origin, and complications are rare.
Recommendation 2. Antibiotics should not be used to treat nonspecific upper respiratory tract infections in previously healthy adults. Purulent secretions from the nares or throat do not predict bacterial infection or benefit from antibiotic treatment. Antibiotic treatment of adults with nonspecific upper respiratory tract infections does not enhance illness resolution or prevent complications.
Recommendation 1. Sinus radiography is not recommended for the diagnosis of uncomplicated sinusitis. The greatest barrier to efficient antibiotic treatment of acute bacterial rhinosinusitis is lack of a simple and accurate diagnostic test. Until a better test is widely available in office practice, the office diagnosis of acute bacterial rhinosinusitis will remain imprecise. Duration of illness is a useful clinical criterion because acute bacterial sinusitis is not common in patients whose symptoms last for less than seven days. Patients who do not have persistent purulent nasal drainage, maxillary facial or tooth pain or tenderness, or both are unlikely to have bacterial rhinosinusitis, regardless of duration of illness.
Recommendation 2. Acute bacterial sinusitis does not require antibiotic treatment, especially if symptoms are mild or moderate. Because most patients with a clinical diagnosis of rhinosinusitis improve without antibiotic treatment, symptomatic treatment or reassurance is the preferred initial management strategy. Appropriate doses of analgesics, antipyretics, and decongestants should be offered, as well as patient education about the chosen management strategy.
Recommendation 3. Patients with severe or persistent moderate symptoms and specific findings of bacterial sinusitis should be treated with antibiotics. Narrow-spectrum antibiotics are reasonable first-line agents. In most cases, antibiotics should be used only for patients with the specific findings of persistent purulent nasal discharge and facial pain or tenderness who are not improving after seven days or those with severe symptoms of rhinosinusitis, regardless of duration. On the basis of clinical trials, amoxicillin, doxycycline, or trimethoprim-sulfamethoxazole are the favored antibiotics.
Recommendation 1. All patients with pharyngitis should be offered appropriate doses of analgesics, antipyretics, and other supportive care. The overwhelming majority of adults with acute pharyngitis have self-limited illness, which would do well with supportive care only. Some suggested supportive care includes analgesics (both systemic and topical), antipyretics, and gargles.
Recommendation 2. Physicians should limit antimicrobial prescriptions to patients who are most likely to have Group A-hemolytic streptococcus (GABHS). That is the causal agent in approximately 10% of adult cases of pharyngitis. The benefits of antibiotic treatment of adult pharyngitis are limited to patients with GABHS infection. Recommended strategies include:
• Empirical antibiotic treatment of adults with at least three of four clinical criteria (history of fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough) shown to be associated with GABHS pharyngitis. Non-treatment is advised for all others.
• Empirical treatment of adults with all four clinical criteria, rapid-antigen testing of patients with three (or perhaps two) clinical criteria, and treatment of those with positive test results. Non-treatment is advised for all others.
Recommendation 3. The preferred antimicrobial agent for treatment of acute GABHS pharyngitis is penicillin, or erythromycin in penicillin-allergic patients.
Recommendation 1. The evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis should focus on clinically ruling out pneumonia. In the healthy, nonelderly adult, 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 three weeks or longer, chest radiography is warranted in the absence of other known causes.
Recommendation 2. Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. Most patients with uncomplicated acute bronchitis have a viral illness that is self-limited and will improve on its own, with or without relief of symptoms. Although relief of symptoms will not shorten duration of illness, patients can certainly benefit from such treatments as analgesic or antipyretic agents, inhalers, antitussives, and vaporizers.