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New best practices guidelines for upper-respiratory diseases
If the much-feared post-antibiotic era ever truly arrives, an outpatient may well be carrying its banner.
Patient pressures, diagnostic difficulties, and even professional competition among physicians all contribute to the staggering misuse of antibiotics in ambulatory settings. For example, millions of people annually are being prescribed antibiotics for colds or bronchitis of viral origin.
"We are very concerned about the rise in resistance to antibiotics, and the vast majority of antibiotics are prescribed in the outpatient setting," says Richard E. Besser, MD, medical epidemiologist in the respiratory diseases branch of the Centers for Disease Control and Prevention.
Besser and collaborating clinicians have authored a series of articles that go beyond the typical guidelines and warnings, instead specifying precise clinical situations when antibiotics should be used or avoided in adult outpatients. While the CDC participated in the development of the recommendations, the guidelines were issued by the American College of Physicians and the American Society of Internal Medicine in the March 20, 2001 issue of the Annals of Internal Medicine.1-9 (See recommendations, p. 2.)
The majority of antibiotics prescribed to adult outpatients are for acute respiratory tract infections, including sinusitis, pharyngitis, bronchitis, and the all too-common cold. Accordingly, clinicians drew their sights on this group of infections.
"These principles are directed at otherwise healthy adults, so we are not dealing with a group of patients with a lot of underlying chronic illness," Besser emphasizes. "In this group of patients, an undifferentiated upper respiratory tract infection is otherwise known as the common cold. That is viral. Antibiotics have no role in treating the common cold. It’s a simple message, but when you look at antibiotic prescribing data, there are a lot of antibiotics that are prescribed for that condition."
Patient campaign may follow
Along with clinical guidelines, patient education on antibiotics is desperately needed. "Both sides are important," he says. "[The CDC is] hoping to launch a nationwide advertising campaign to help change the perception of the general public."
As it is now, physicians face unrealistic patient expectations to prescribe antibiotics, but scarcely have the time to do one-on-one education.
"There definitely is a pressure," Besser says. "When we talk to clinicians - if you look at studies and focus groups - patient pressure definitely is a factor. Also [there are] time demands, diagnostic uncertainty, as well as a perception that some of their colleagues might be dispensing antibiotics a little more freely. Those all can lead to a situation where an antibiotic is prescribed when benefit is not likely."
Sometimes, the difference in appropriate and inappropriate drug use comes down to language. For example, researchers are finding that patients are much less likely to expect antibiotics if they are told they have a chest cold. On the other hand, those advised that they have bronchitis - essentially the same condition - often expect antibiotic therapy.
By the same token, the patient’s presentation may legitimately cloud the issue, making it difficult to know whether an antibiotic is needed. But in too many cases the default mentality is when in doubt, prescribe. As a result, researchers report, clinicians identify and treat a subset of upper respiratory tract infections primarily characterized by the presence of purulent manifestations. Reported or observed purulent nasal discharge or production of green phlegm, presence of tonsillar exudates, and current tobacco use emerge as independent predictors of antibiotic treatment of upper-respiratory infection, they report.
As a result of such injudicious use, pathogens like Streptococcus pneumoniae are becoming increasingly resistant. It is the leading cause of community-acquired bacterial pneumonia, bacterial meningitis, bacterial sinusitis, and otitis media in the United States. Previous antibiotic use is the most important factor in carriage of and infection with antibiotic-resistant S. pneumoniae. "It used to be that pneumococcal infection could easily be treated with penicillin," Besser says. "That’s not the case anymore, so we are definitely concerned."
Yet studies show the prevalence of antibiotic-resistant S. pneumoniae and group A streptococcus decreases when antibiotic use is cut back in communities. While resistance is the dominant concern, the authors of the clinical practice guidelines also note that stemming the antibiotic tide in outpatients could spare them side effects that can be serious. Such efforts also reduce costs for both consumers and insurers. Still, that does not mean that legitimate bacterial infections should go untreated.
"We need to be careful and make sure the pendulum doesn’t swing to far in the other direction," Besser cautions. "Antibiotics have a role in the treatment of bacterial infections. I would hate to see the outcome of principles like this be that patients who could benefit from antibiotic therapy no longer receive it."
For example, a patient who truly has bacterial sinusitis should be treated with an antibiotic, he says. "A patient who has documented group A strep pharyngitis can benefit from an antibiotic," he adds. "The issue is trying to determine which patients will benefit."
When antibiotic therapy is prescribed, the preference is a laser - not a shotgun. Clinicians should avoid broad-spectrum agents if possible. Such drugs could stir selective pressure for resistance in bugs that aren’t even causing the infection at hand. "You want to target your therapy at what are the most-likely organisms," Besser says. "Then you are not [prescribing] the widest spectrum possible."
1. Gonzales R, Bartlett JG, Besser RE, 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; 134:479-486.
2. Snow V, Mottur-Pilson C, Gonzales R, et al. Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults. Ann Intern Med 2001; 134:487-489.
3. Gonzales R, Bartlett JG, Besser RE, 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; 134:490-494.
4. Snow V, Mottur-Pilson C, Hickner JM. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Intern Med 2001; 134:495-497.
5. Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: Background. Ann Intern Med 2001; 134:498-505.
6. Snow V, Mottur-Pilson C, Cooper RJ, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med 2001; 134:506-508.
7. Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Ann Intern Med 2001; 134:509-517.
8. Snow V, Mottur-Pilson C, Gonzales R, et al. Principles of appropriate antibiotic use for treatment of acute bronchitis in adults. Ann Intern Med 2001; 134:518-520.
9. Gonzales R, Bartlett JG, Besser, RE et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: Background. Ann Intern Med 2001; 134: 521-529.