Guidelines for the Use of Antibiotics in Acute Upper Respiratory Tract Infections DAVID M. WONG, D.O., Arrowhead Regional Medical Center, Colton, California DEAN A. BLUMBERG, M.D., University of California at Davis Medical Center, Sacramento, California LISA G. LOWE, M.D., M.P.H., University of California at San Diego Medical Center, San Diego, California To help physicians with the appropriate use of antibiotics in children and adults with upper respiratory tract infection, a multidisciplinary team evaluated existing guidelines and summarized key practice points. Acute otitis media in children should be diagnosed only if there is abrupt onset, signs of middle ear effusion, and symptoms of inflammation. A period of observation without immediate use of anti- biotics is an option for certain children. In patients with sinus infec- tion, acute bacterial rhinosinusitis should be diagnosed and treated with antibiotics only if symptoms have not improved after 10 days or have worsened after five to seven days. In patients with sore throat, a diagnosis of group A beta-hemolytic streptococcus pharyngitis gener- ally requires confirmation with rapid antigen testing, although other lou guidelines allow for empiric therapy if a validated clinical rule suggests PE ara a high likelihood of infection. Acute bronchitis in otherwise healthy W. K N H adults should not be treated with antibiotics; delayed prescriptions O may help ease patient fears and simultaneously reduce inappropriate use of antibiotics. (Am Fam Physician 2006;74:956-66, 969. Copyright © 2006 American Academy of Family Physicians.) ILLUSTRATION BY J Patient information: he Centers for Disease Control and have found no association between receiv- A handout on when to use Prevention (CDC) estimates that ing an antibiotic prescription and satisfac- antibiotics, written by the authors of this article, is more than 100 million antibiotic tion with the office visit. What does impact provided on page 969. prescriptions are written each year satisfaction is whether patients understood T in the ambulatory care setting.1 With so many their illness after the visit and whether they prescriptions written each year, inappropri- felt that their physician spent enough time ate antibiotic use will promote resistance. In with them. addition to antibiotics prescribed for upper Increased antibiotic resistance is not respiratory tract infections with viral etiolo- inevitable. For example, Finland demon- gies, broad-spectrum antibiotics are used too strated the success of a nationwide effort often when a narrow-spectrum antibiotic to reduce antibiotic resistance following an would have been just as effective.2 This mis- increase in erythromycin resistance among use of antibiotics has led to the development patients with group A streptococci in the of antibiotic-resistant bacteria. early 1990s.4 Nationwide recommendations In one study, up to 50 percent of parents were developed for the appropriate use of had a previsit expectation of receiving an macrolide antibiotics; these efforts led to a antibiotic prescription for their children, reduction in the use of macrolides and a sub- and one third of physicians perceived an sequent decrease in the rate of erythromycin expectation for a prescription.3 Because of resistance. these expectations and the time constraints This article presents guidelines that were on physicians, prescribing an antibiotic may developed by the Alliance Working for seem preferable to explaining why an anti- Antibiotic Resistance Education (AWARE) biotic is unnecessary. However, researchers Project, with support from the California Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2006 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Clinical criteria that assist in the diagnosis of acute otitis media include C 6 the abrupt onset of signs and symptoms, the presence of middle ear effusion, and signs or symptoms of middle ear inflammation. A period of observation is appropriate for select children with acute C 6 otitis media and nonsevere symptoms. A diagnosis of acute bacterial rhinosinusitis should be considered in C 7 patients with symptoms of a viral upper respiratory infection that have not improved after 10 days or that worsen after five to seven days. Treatment of sinus infection with antibiotics in the first week of C 7 symptoms is not recommended. Amantadine (Symmetrel) and rimantadine (Flumadine) should not be A 23 used for the treatment of influenza because of widespread resistance. Acute bronchitis in otherwise healthy adults should not be treated A 14 with antibiotics. Telling patients not to fill an antibiotic prescription unless symptoms B 24, 25 worsen or fail to improve after several days can reduce the inappropriate use of antibiotics. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 906 or http://www.aafp.org/afpsort.xml. Medical Association Foundation. This the practice guidelines developed for each project began in January 2000. More than disease by the leading medical organizations 80 organizations are partners in the AWARE were compiled. Members of the work group Project (http://www.aware.md). The work then prioritized the reference articles and group is composed of practicing physicians, guidelines to be included in the academic physicians, pharmacists, and review process. The compendia nurses. No one from the pharmaceutical are shown in Tables 1 and 2.5 Early treatment of sinus industry was involved in the development of infection with antibiotics the compendia. Otitis Media in Children is not recommended Given the breadth of this topic, the focus The American Academy of unless symptoms are of this article is on the appropriate use of Family Physicians (AAFP)/ prolonged and worsening antibiotics and not on the use of adjunctive American Academy of Pediat- significantly. treatments such as antitussives, deconges- rics (AAP) guideline for otitis tants, and inhalers, although they play an media in children focuses on important role in disease management and three major points: accurate diagnosis, an symptomatic relief. The guidelines discussed assessment of pain, and judicious use of anti- here address the care of otherwise healthy biotics with an option for watchful waiting in patients without major comorbidities in the select patients.6 outpatient setting. ACCURATE dIAGNOSIS Guideline Development Process Three elements must be met to confirm the A work group was formed in late 2001 to diagnosis of acute otitis media. The first ele- provide overall direction in the development ment is the recent, usually abrupt onset of of clinical practice materials and resources. signs and symptoms of middle ear inflamma- The process began with a literature search tion and effusion. The second element is the for each respiratory tract infection. Next, presence of middle ear effusion as indicated September 15, 2006 ◆ Volume 74, Number 6 www.aafp.org/afp American Family Physician 957 tablE 1 Clinical Practice Guidelines Compendium: Children with URI Illness/pathogen Indications for antibiotic treatment Treatment Antibiotic Otitis media When to treat with an antibiotic: recent, usually abrupt onset of signs and Age group First-line therapy Streptococcus pneumoniae, nontypeable symptoms of middle ear inflammation and effusion Younger than six months: antibiotics High-dosage amoxicillin (80 to 90 mg per kg per day) Haemophilus influenzae, Moraxella and Six months to two years: antibiotics if If severe illness or additional coverage desired: catarrhalis Presence of middle ear effusion that is indicated by any of the following: bulging of the diagnosis certain; antibiotics if diagnosis high-dosage amoxicillin/clavulanate (Augmentin; tympanic membrane, limited or absent mobility of tympanic membrane, air fluid level uncertain and severe illness 80 to 90 mg per kg per day of amoxicillin behind the tympanic membrane, otorrhea Older than two years: antibiotics if diagnosis component) and certain and severe illness Alternative therapy Signs or symptoms of middle ear inflammation as indicated by distinct erythema of the Analgesics and antipyretics Nonanaphylactic penicillin-allergic: cefdinir (Omnicef), tympanic membrane Always assess pain. If pain is present, cefpodoxime (Vantin), or cefuroxime (Ceftin) or treatment to reduce pain Severe penicillin allergy: azithromycin (Zithromax) or Distinct otalgia (discomfort clearly referable to the ear[s] that interferes with or Oral: ibuprofen or acetaminophen (may clarithromycin (Biaxin) precludes normal activity or sleep) use acetaminophen with codeine for Unable to tolerate oral antibiotic: ceftriaxone When not to treat with an antibiotic: otitis media with effusion moderate-severe pain) (Rocephin) Topical: benzocaine Acute bacterial sinusitis When to treat with an antibiotic: diagnosis of acute bacterial sinusitis may be made Usual antibiotic duration: 10 days First-line therapy S. pneumoniae, nontypeable with symptoms of viral URI (nasal discharge or daytime cough not improved after Failure to respond after 72 hours