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Appropriate Antibiotic Use for Acute Upper Respiratory Infections in Adults

Target population: Primary care providers in an ambulatory setting.

Sponsoring Organization: Centers for Disease Control and Prevention expert panel of internists, family practitioners, and emergency medicine and infectious diseases specialists.

Type: Consensus statements based on evidence-based medicine.

Key Points: Acute upper respiratory infections constitute the most common group of illnesses for which adults seek ambulatory medical attention. Nearly all of these infections are caused by viruses, against which antibiotics are ineffective -- yet these illnesses account for up to 75 percent of the antibiotic prescriptions written in the U.S. Reducing unnecessary antibiotic use is the principal strategy for combating the emergence of antibiotic resistance, and this group of syndromes represents a highly appropriate target for rationalizing and limiting antibiotic use.

The panel divides upper respiratory infection into the categories of pharyngitis, rhinosinusitis, uncomplicated acute bronchitis, and nonspecific infections, including the common cold. For each of these syndromes, they provide data as background to demonstrate the preponderance of viral etiologies and the concomitant uselessness of antibiotic administration. They make specific recommendations for identifying those relatively infrequent cases in which bacteria might play a role and for which antibiotics would be a rational therapeutic choice. The algorithm for diagnosing pharyngitis is most interesting, in that it doesn't include routine throat culture but relies instead on clinical criteria (tonsillar exudates, tender anterior cervical adenopathy, absence of cough, and history of fever), bolstered, when only 2 or 3 of these are present, with rapid antigen testing. Although use of rapid antigen testing doesn't affect antibiotic overuse directly, it is unnecessary and expensive. In the rhinosinusitis guideline, sinus radiography is not recommended for routine work-up of this syndrome.

The guidelines do not apply to children, immunocompromized adults, or those with underlying chronic respiratory disease. The authors emphasize the role of patient expectations in the prescribing of antibiotics but do not provide suggestions for dealing with these unwarranted expectations.

Comment: The 9 position papers comprising these guidelines are well referenced and clearly expressed, if somewhat redundant in their background statements. Emerging antibiotic resistance has been inextricably linked to the overuse and misuse of antibiotics. It will be the most significant infectious diseases problem of the coming decade. These guidelines are the first to target upper respiratory infection as an appropriate starting place for the assault on the insupportable practice of useless antibiotic administration.

— S Baum

Published in Journal Watch Infectious Diseases April 27, 2001

Citation(s):

Gonzales R et al. Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: Background, specific aims and methods. Ann Intern Med 2001 Mar 20 134 479 -486.

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Snow V et al. Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults. Ann Intern Med 2001 Mar 20 134 487 -489.

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Gonzales R et al. Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults: Background. Ann Intern Med 2001 Mar 20 134 490 -494.

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Snow V et al. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Intern Med 2001 Mar 20 134 495 -497.

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Hickner JM et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: Background. Ann Intern Med 2001 Mar 20 134 498 -505.

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Snow V et al. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med 2001 Mar 20 134 506 -508.

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Cooper RJ. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Ann Intern Med 2001 Mar 20 134 509 -517.

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Snow V et al. Principles of appropriate antibiotic use for treatment of acute bronchitis in adults. Ann Intern Med 2001 Mar 20 134 518 -520.

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Gonzales R et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: Background. Ann Intern Med 2001 Mar 20 134 521 -529.

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