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Acute Respiratory Tract Infection in Adults

ACP guidelines look at appropriate antibiotic use

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The American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC) has issued clinical guidelines on the appropriate antibiotic use of acute respiratory tract infection (ARTI) in adults. The guidelines include advice for high-value care, including:

High-Value Care Advice 1: Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected.

High-Value Care Advice 2: Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis (for example, persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate combination of symptoms) by rapid antigen detection test and/or culture for group A Streptococcus. Clinicians should treat patients with antibiotics only if they have confirmed streptococcal pharyngitis.

High-Value Care Advice 3: Clinicians should reserve antibiotic treatment for acute rhinosinusitis for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening sign).

High-Value Care Advice 4: Clinicians should not prescribe antibiotics for patients with the common cold.

Citation: Harris AM, Hicks LA, Qaseem A, et al. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. [Published online ahead of print January 19, 2016]. Ann Intern Med. doi: 10.7326/M15-1840.

Commentary: ARTIs are the most common reason for antibiotic prescriptions in ambulatory practice. There are more than 100 million antibiotic prescriptions written by office-based practices annually and over 40% of those prescriptions are for ARTIs. Antibiotics account for 1 in 5 emergency room visits for adverse drug reactions, and it is estimated that 5% to 25% of patients who are prescribed antibiotics have an adverse reaction, with 1 in 1,000 being a serious adverse event. Adverse effects of antibiotics are both short and long-term. The short-onset adverse events may be mild in severity and include rash, diarrhea, and abdominal pain, moderate in severity such as c. difficile diarrhea, or may be severe and may include anaphylaxis. The major long-term adverse effect is the increase in antibiotic resistant bacteria. Antibiotic resistance occurs both at a population level and at an individual level. This clinical guideline reinforces the importance of correct antibiotic prescribing. —Neil Skolnik, MD

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