Aaron M. Harris, MD, MPH; Lauri A. Hicks, DO; Amir Qaseem, MD, PhD, MHA; for the High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention (*)
Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Acknowledgment: The authors thank Dr. Adam Hersh from the University of Utah for his thoughtful review and feedback in the development of this manuscript.
Financial Support: Financial support for the development of this guideline comes exclusively from the operating budgets of ACP and the Centers for Disease Control and Prevention.
Disclosures: Dr. Moyer reports that she is Chair of the Board of Governors of the American College of Physicians. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1840. Any financial and nonfinancial conflicts of interest of the group members were declared, discussed, and resolved. A record of disclosures of interest is kept for each High Value Care Task Force meeting and conference call and can be viewed at http://hvc.acponline.org/clinrec.html.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Dr. Harris: Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA 30329.
Dr. Hicks: Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop A-07, Atlanta, GA 30329.
Dr. Qaseem: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Author Contributions: Conception and design: A.M. Harris, L.A. Hicks, A. Qaseem.
Analysis and interpretation of the data: A.M. Harris, L.A. Hicks, A. Qaseem.
Drafting of the article: A.M. Harris, L.A. Hicks, A. Qaseem.
Critical revision of the article for important intellectual content: A.M. Harris, L.A. Hicks, A. Qaseem.
Final approval of the article: A.M. Harris, L.A. Hicks, A. Qaseem.
Statistical expertise: A. Qaseem.
Obtaining of funding: A. Qaseem.
Administrative, technical, or logistic support: A.M. Harris, L.A. Hicks, A. Qaseem.
Collection and assembly of data: A.M. Harris.
Acute respiratory tract infection (ARTI) is the most common reason for antibiotic prescription in adults. Antibiotics are often inappropriately prescribed for patients with ARTI. This article presents best practices for antibiotic use in healthy adults (those without chronic lung disease or immunocompromising conditions) presenting with ARTI.
A narrative literature review of evidence about appropriate antibiotic use for ARTI in adults was conducted. The most recent clinical guidelines from professional societies were complemented by meta-analyses, systematic reviews, and randomized clinical trials. To identify evidence-based articles, the Cochrane Library, PubMed, MEDLINE, and EMBASE were searched through September 2015 using the following Medical Subject Headings terms: “acute bronchitis,” “respiratory tract infection,” “pharyngitis,” “rhinosinusitis,” and “the common cold.”
Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected.
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.
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).
Clinicians should not prescribe antibiotics for patients with the common cold.
Table. Antibiotic Prescribing Strategies for Adult Patients With Acute Respiratory Tract Infection
Summary of the American College of Physicians and Centers for Disease and Control and Prevention advice for high-value care on appropriate antibiotic use for acute respiratory tract infection in adults.
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Jan Matthys, MD.
University of Ghent, Belgium. Department of General Practice. firstname.lastname@example.org
January 25, 2016
Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: different advices for pharyngitis.
Dear editor,The advice that ‘clinicians should test patients with symptoms suggestive of group A streptococcal (GAS) pharyngitis by rapid antigen detection test (RAT) and/or culture for group A Streptococcus’ (1) is not in agreement with different European guidelines. (2)The problem with GAS is that there is no sufficient reliability of clinical findings and tests, even in combination. According to the guidelines from the UK National Institute for Health and Care Excellence and the Scottish Intercollegiate Guidelines Network (NICE/SIGN) (3), neither RAT nor throat swab culture can differentiate between the streptococcal carrier state and invasive infection.Reflexive culture with throat swab has a poor sensitivity (73%–80%); results take up to 48 hours to be reported which is too late to significantly influence the clinical course (3); there is an asymptomatic carriage range from 6% to 40%: Streptococcus can live in our noses, mouths, and throats and not make us sick, which means that having a positive RAT or culture does not necessarily mean there is an infection. Swabs may be useful in high-risk groups, to guide the choice of treatment if treatment failure occurs. (3)Increasingly more and European guidelines consider acute sore throat a self-limiting disease (2). Antibiotics are prescribed immediately only when the patient has risk factors, decreased immunocompetence, or extreme illness (approximately 5% of cases). (2)Antibiotics should not be used to secure symptomatic relief in sore throat. (3) One or 2 days of extra acetaminophen/paracetamol (or nonsteroidal anti-inflammatory drugs) every 4 hours can replace unnecessary antibiotic use in most cases and might reduce the problem of antibiotic resistance.When the patient does not improve within 2 or 3 days, the physical examination must be repeated to exclude peritonsillar abscess and even the Lemierre syndrome.(4)The conclusion is that in patients with respiratory infections where clinicians feel it is safe not to prescribe antibiotics immediately, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use, while maintaining similar patient satisfaction. (5)We applaud that the guideline does not recommend tonsillectomy solely to reduce the frequency of group A streptococcal pharyngitis in adults. (1)1. Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. 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. Ann Intern Med. 2016 Jan 19. doi: 10.7326/M15-18402. Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. 2007; 5:436-43.3. National Institute of Clinical Excellence. Clinical knowledge summaries. 2012. Great Britain. SIGN. Scottish Intercollegiate Guidelines Network. Available at: http://cks.nice.org.uk/sore-throat-acute, http://www.sign.ac.uk/. Accessed 2010.4. Matthys J, De Meyere M, De Sutter A. Fusobacterium-Positive and Streptococcal-Positive Pharyngitis. Ann Intern Med. 2015 Jun 16;162:876. doi: 10.7326/L15-5099.5. Spurling GK, Del Mar CB, Dooley L, Foxlee R, Farley R Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev 2013;4:CD004417.
Carl Llor, Ana Moragas
GP and senior researchers. Primary Healthcare Center Manso-Via Roma
February 2, 2016
Conflict of Interest:
CL reports a grant from the Jordi Gol i Gurina Foundation for a research stage at the University of Cardiff in 2013, as well as research grants from the European Commission (Sixth and Seventh Programme Frameworks, and Horizon 2020), Catalan Society of Family Medicine, and Instituto de Salud Carlos III.
Guidelines on appropriate antibiotic use for acute respiratory tract infections
The four high-value care recommendations described in the recently published guidelines on appropriate antibiotic use for acute respiratory tract infections (RTI) in adults are very clear, thereby assisting clinicians in providing the best care for patients as well as reducing variations and arbitrariness in practice (1). Notwithstanding, clinical guidelines are particularly challenging to apply to some groups in which the evidence is not sufficiently solid, such as in very severe infections and elderly patients with multiple comorbidities. Clinical trials comparing antibiotic and placebo very often do not include this kind of patients, the so-called ‘special’ cases. The key question is how applicable clinical guidelines are to these patients. In addition, a fear of complications as well as complacency and the existence of different guidelines across countries, i.e. acute pharyngitis, may explain the greater prescription of antibiotics for processes for which they are not indicated (2). This is why clinical practice guidelines have been criticized as being disease-driven rather than patient-driven (3). The new Spanish guidelines on RTIs in primary care clearly state that antibiotics are never required for the common cold and influenza. However, there are some situations of otitis media, rhinosinusitis, pharyngitis, acute bronchitis and exacerbations of chronic obstructive pulmonary disease for which antibiotics are warranted. Moreover, in an attempt to consider this grey area these guidelines also define categories of patients for whom clinicians might consider prescribing an antibiotic, recommending in these cases, for instance, delayed prescribing of antibiotics, which has recently been shown to be an effective way of reducing antibiotic consumption in Spain (4).With the aim of evaluating the percentage of cases for which antibiotics may be prescribed, we carried out an audit-based study from January to March 2015, in which a total of 248 general practitioners throughout Spain registered all cases with RTIs over a 3-week period, including a total of 11,137 patients. The overall antibiotic prescribing rate was 27.2% whereas they should have only been definitely prescribed in 7.5% of the cases and might have been prescribed in another 6.4% according to these guidelines. Doctors know that unnecessary antibiotics expose patients to adverse drug reactions and increase the prevalence of antibiotic-resistant bacteria but uncertainty in some cases makes the therapeutic decision of antibiotic prescription difficult in practice and guidelines should also endorse these situations. However, even with the use of conservative guidelines, current antibiotic prescription clearly surpasses the recommended rate.References1. Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. 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. Ann Intern Med 2016 Jan 19. doi: 10.7326/M15-1840.2. González-González C, López-Vázquez P, Vázquez-Lago JM, Piñeiro-Lamas M, Herdeiro MT, Chávarri Arzamendi P, Figueiras A, and GREPHEPI Group. Effect of physicians' attitudes and knowledge on the quality of antibiotic prescription: A cohort study. PLoS One. 2015;10:e0141820. 3. Tinetti ME, Bogardus ST, Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004;351:2870–4.4. de la Poza Abad M, Mas Dalmau G, Moreno Bakedano M, González González AI, Canellas Criado Y, Hernández Anadón S, et al; Delayed Antibiotic Prescription (DAP) Group. Prescription strategies in acute uncomplicated respiratory infections: A randomized clinical trial. JAMA Intern Med 2016;176:21–9.
Aaron M. Harris, MD, Lauri A. Hicks, DO, Amir Qaseem, MD, PhD
Center for Disease Control, American College of Physicians
May 13, 2016
We appreciate Dr. Matthys’s comments (1) and acknowledge that even when patients with pharyngitis meet recommended criteria for group A streptococcal (GAS) testing, as many as 20% of children and fewer adults will have a positive result from colonization rather than true disease (2). This leads to overuse of antibiotics for pharyngitis.
In a recent study examining outpatient antibiotic prescribing, pharyngitis was one of the conditions for which antibiotics were most commonly prescribed; 56% and 72% of pediatric and adult pharyngitis cases, respectively, resulted in an antibiotic prescription far exceeding estimates of the true prevalence of GAS infection and colonization (37% for children and 18% for adults) (3). This suggests that in many cases providers are either not testing for GAS or are prescribing antibiotics despite a negative test result. The 2012 Infectious Diseases Society of America (IDSA) clinical guideline for diagnosis and management of GAS pharyngitis recommends testing for GAS in patients with clinical symptoms suggestive of GAS pharyngitis and prescribing antibiotics for patients with a positive GAS test result (4). An important first step in reducing unnecessary antibiotic use in the United States would be to follow the IDSA recommendation to only treat patients with positive GAS test results. We agree with Dr. Matthys that providers should offer recommendations for symptomatic relief. The Centers for Disease Control and Prevention has developed a symptomatic prescription pad that providers can use to guide symptom management in their patients (http://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/viral-rx-pad-color.pdf).
While acute pharyngitis in adults is usually self-limited, antibiotic treatment in patients with confirmed GAS pharyngitis has been shown to provide modest benefit (4,5). The goals of treatment in patients with GAS pharyngitis are to prevent nonsuppurative complications, reduce the duration of symptoms, and reduce transmission of GAS to close contacts (4,5). The magnitude of the benefit depends on the epidemiology of GAS infections in the region and the risk of post-streptococcal complications. In light of the growing threat of antibiotic resistance and increasing recognition of adverse events associated with antibiotic use, including community-associated Clostridium difficile infection, studies that carefully weigh the benefits and risks of antibiotic treatment for GAS pharyngitis are needed.
1. Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. 2007; 5:436-43.
2. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 8th Edition Edited by John E. Bennett MD MACP, Raphael Dolin MD, Martin J. Blaser MD. Saunders, 2014.
3. Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM, Finkelstein JA, Gerber JS, Hyun DY, Linder JA, Lynfield R, Margolis DJ, May LS, Merenstein D, Metlay JP, Newland JG, Piccirillo JF, Roberts RM, Sanchez G, Suda KJ, Thomas A, Woo TM, Zetts RM, Hicks LA. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016 May 3;315(17):1864-73.
4. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Disease Society of America. Clin Infect Dis. 2012; 55:1279-82.
5. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013; 11:CD000023.
Aaron M. Harris, Lauri A. Hicks, Amir Qaseem, . 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. Ann Intern Med. 2016;164:425–434. doi: 10.7326/M15-1840
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Published: Ann Intern Med. 2016;164(6):425-434.
Published at www.annals.org on 19 January 2016
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