CDC, ACP Issue Guideline on Antibiotic Use for RTIs

Troy Brown, RN

January 18, 2016

The American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC) have released a new clinical guideline on antibiotic use in adults with acute respiratory tract infections (ARTIs).

"Providers should apply strict criteria…to determine when antibiotics are needed," lead author Aaron M. Harris, MD, MPH, LCDR, US Public Health Service, medical epidemiologist, Division of Viral Hepatitis, CDC, said. "Except for confirmed bacterial infections like streptococcal pharyngitis or acute bacterial sinusitis, antibiotics should not routinely be used to treat healthy adults with acute respiratory tract infections at outpatient clinics.…Treatments to relieve symptoms are available and can be used to reduce discomfort."

Dr Harris and colleagues for the High Value Care Task Force of the ACP and for the CDC published the clinical guideline January 19 in Annals of Internal Medicine.

ARTIs include acute uncomplicated bronchitis, pharyngitis, rhinosinusitis, and the common cold. The CDC estimates that half of antibiotic prescriptions in the outpatient setting may be unnecessary or inappropriate.

"Overuse of antibiotics contributes to the spread of antibiotic resistance, which has led to approximately two million people developing antibiotic-resistant illnesses and 23,000 associated deaths in the United States each year. Furthermore, antibiotics are a leading reason for emergency room visits for drug side effects, responsible for one of every five visits," Dr Harris told Medscape Medical News.

"Antibiotics can cause serious adverse events including allergic reactions, C difficile–associated diarrhea, and super infections with multidrug-resistant organisms. These adverse events account for more than $30 billion in excess healthcare costs each year," he continued.

"[T]he clinical guideline will serve as a guide for outpatient healthcare providers to promote the recommended use of antibiotics for healthy adults with acute respiratory tract infections," Dr Harris explained.

Patients With Bronchitis

Do not perform testing or start antibiotic therapy in patients with bronchitis unless pneumonia is suspected. Symptomatic treatment may include cough suppressants, expectorants, antihistamines, decongestants, and βagonists.

Patients With Suspected Group A Streptococcus

Test patients whose symptoms suggest group A streptococcal pharyngitis (persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate group of symptoms) using a rapid antigen detection test and or/culture. Give antibiotics only to those with confirmed streptococcal pharyngitis.

For those with sore throat, clinicians should recommend analgesics such as aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs, and throat lozenges, which can ease pain. Reassure patients that sore throat usually lasts for less than 1 week and that antibiotics are usually unnecessary and may have side effects.

Patients With Acute Rhinosinusitis

For patients with acute rhinosinusitis, save antibiotic treatment for those with persistent symptoms lasting more than 10 days, onset of severe symptoms, or signs of temperature higher than 39°C/102.2°F, and purulent nasal discharge or facial pain that lasts at least 3 consecutive days, or development of worsening symptoms after a typical viral illness that lasted 5 days and had begun improving (double sickening).

Patients With Common Cold

Do not prescribe antibiotics for those with the common cold. Educate patients that symptoms can last as long as 2 weeks and to follow up if symptoms get worse or last longer than expected. Explain the risks and benefits of treating symptoms only and that antibiotics are unnecessary. Instruct patients on symptomatic treatment.

Clinicians Control the Prescription Pad

"Although it is everyone's responsibility to use antibiotics appropriately, providers have the power to control prescriptions. Reducing inappropriate antibiotic prescribing will improve quality of care, decrease health care costs, and preserve the effectiveness of antibiotics," the authors conclude.

"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, in an ACP news release. "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."

Coauthor Darilyn V. Moyer, MD, reports that she is chair of the Board of Governors of the ACP. The authors have reported no relevant financial relationships. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1840.

Ann Intern Med. Published online January 19, 2016. Full text

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