In a paper published today in Annals of Internal Medicine, the American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC) issued advice for prescribing antibiotics for acute respiratory tract infections (ARTIs) in adults. “Inappropriate use of antibiotics for ARTIs is an important factor contributing to the spread of antibiotic-resistant infections, which is a public health threat,” said ACP President Wayne J. Riley, MD, MPH, MBA, MACP. “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.”
ARTIs, including the common cold, uncomplicated bronchitis, sore throat, and sinus infection, are the most common reason for doctor’s office visits. According to unpublished CDC data, an estimated 50 percent of antibiotic prescriptions may be unnecessary or inappropriate in the outpatient setting, which equates to over $3 billion in excess costs. Antibiotics also are responsible for the largest number of medication-related adverse events and the cause of about one in five visits to emergency departments for adverse drug reactions.
Physicians should not prescribe antibiotics for patients with the common cold. Physicians should advise patients that symptoms can last up to two weeks and to follow up if symptoms worsen or exceed the expected time of recovery. Physicians should also explain the risks and benefits of symptomatic therapy and that antibiotics are not needed and may have side effects. Symptomatic therapy is recommended for management of common cold symptoms.
For patients with uncomplicated bronchitis, physicians should not perform testing or prescribe antibiotics unless pneumonia is suspected. Patients may benefit from symptomatic relief with cough suppressants, expectorants, antihistamines, decongestants, and beta agonists.
For patients with sore throat, physicians should recommend analgesic therapy such as aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs, and throat lozenges, which can help reduce pain. Physicians can reassure patients that the usual course of a sore throat is less than one week and that antibiotics are not usually needed because they do little to improve symptoms and may have side effects.
Physicians should test patients with symptoms suggestive of group A streptococcal pharyngitis (for example, persistent fevers or other appropriate combination of symptoms) by rapid strep test and/or culture for group A Streptococcus. Physicians should treat patients with antibiotics only if they have confirmed streptococcal pharyngitis.
Uncomplicated sinus infection usually resolves without antibiotics, even in patients with a bacterial cause. The majority of patients diagnosed with sinus infection experience more side effects than benefits from antibiotics. Most patients with sinus infection should be managed with supportive care. Analgesics may be offered for pain and antipyretics for fever.
Physicians should reserve antibiotic treatment for sinus infection for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (greater than 102.2°F) and nasal discharge or facial pain lasting for at least three consecutive days, or onset of worsening symptoms following a typical viral illness that lasted five days which was initially improving (double-sickening).
The paper includes evidence-based strategies to help physicians promote appropriate antibiotic prescriptions. Physicians can label bronchitis as a “chest cold” or a “viral upper respiratory infection,” and provide patient information sheets about appropriate antibiotic use and alternatives to antibiotics for managing symptoms.
Patients and physicians can work together to prevent overuse of antibiotics. A symptomatic “prescription” pad can be used to provide recommendations for management of symptoms and offer the possibility of future antibiotic treatment if the condition fails to improve.