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Guidelines for Antibiotic Use in Acute Respiratory Infections

Indiscriminate prescription of antibiotics for respiratory infections in ambulatory settings has contributed to the increasing prevalence of antibiotic-resistant Streptococcus pneumoniae. Therefore, the CDC convened a panel of experts to produce evidence-based practice guidelines aimed at decreasing inappropriate antibiotic use.

The guidelines recommend against the use of antibiotics for nonspecific upper respiratory tract infections (URTIs) in previously healthy adults. URTI is defined as an infection in which pharynx, sinus, and lower airway symptoms are not prominent. The authors note that purulence from the nares or throat are common in URTIs and do not predict bacterial infection.

For acute bacterial sinusitis, the guidelines state that antibiotics should be used when symptoms are severe. Mildly to moderately symptomatic infections should be treated with analgesics, antipyretics, and decongestants, but not with antibiotics unless symptoms are moderate, persist for at least 7 days, and include 1 of the following: purulent nasal drainage, maxillary facial pain, or tooth pain or tenderness. Amoxicillin, doxycycline, and trimethoprim-sulfamethoxazole are favored for these cases.

Adults with pharyngitis and at least 3 of the following clinical criteria -- fever, exudate, tender anterior cervical adenopathy, and absence of cough -- should be treated with penicillin or erythromycin. An alternative is to always treat patients with 4 criteria and to treat those with 2 or 3 criteria only if rapid antigen tests are positive.

Finally, the panel recommended clinically excluding pneumonia in acute cough illness or presumptive uncomplicated acute bronchitis. They advised against antibiotic treatment for acute uncomplicated bronchitis regardless of cough duration, but suggested bronchodilator use. In an accompanying evidence review, the authors point out that the patient-centered quality of physician-patient encounters, rather than the prescription of antibiotics, determined patient satisfaction.

Comment: These guidelines and the accompanying evidence reviews should serve as useful references when deciding how to manage very common acute illnesses. The recommendations can help clinicians limit antibiotic use to proven indications. How much these guidelines will affect clinical practice remains to be seen. Updates will be provided, and more information about antibiotic resistance can be found at http://www.cdc.gov/ncidod/dbmd/antibioticresistance/.

— R Saitz

Published in Journal Watch General Medicine March 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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• Medline abstract (Free)

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.

• Original article (Subscription may be required)
• Medline abstract (Free)

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

• Original article (Subscription may be required)
• Medline abstract (Free)

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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• Medline abstract (Free)

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

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• Medline abstract (Free)

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.

• Original article (Subscription may be required)
• Medline abstract (Free)

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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• Medline abstract (Free)