I recently spent some time working in Fast Track, and with the well published influenza epidemic in New York, I was flooded with well-meaning New Yorkers convinced that their runny noses, coughs and sore throats represented something more than a simple cold. All of this got me thinking about acute upper respiratory infections, and when there is an indication for antibiotic therapy.
Thankfully, the American Academy of Family Physicians recently published guidelines on this very topic.1 I know a topic like this isn’t sexy, but turns out that 99% of Emergency Medicine isn’t sexy, and improving our care of these ‘boring’ problems can impact a huge number of patients (shout out to boringem).
The crux of the article focuses on when antibiotics are indicated. Approximately 25 million people per year show up to their family doc with an uncomplicated URI, and shockingly 65% of patients left with a prescription for an antibiotic.2 I understand that this data comes from patients presenting to their family physician, but if you practice in a patient population like mine where access to primary care is limited and patients wait >3 months for a clinic appointment, we’re seeing more and more URI’s in the ED. Here are some of the highlights from the guidelines:
Rhinosinusitis – consider bacterial >10 days Sx duration or worsening symptoms after initial improvement HOWEVER cure rates between bacterial and viral equivocal regardless of antibiotic therapy!3
Laryngitis – Cochrane review showed antibiotics DO NOT lead to reduced duration of symptoms or voice improvement, infections are self limited viral diseases.4
Bronchitis – NIH, CDC and a 2004 Cochrane review do not recommend antibiotics. Even with cases caused by Bordetella pertussis, and atypical bacteria such as Chlamydia pneumonia, and Mycoplasma pneumoniae, antibiotic are not indicated.5-7 These infections are self-limited (except in rare case of developing pneumonia or the immunocompromised).
An in-depth knowledge of these illnesses allow EP’s to have informed discussions with patients about their disease processes. I’ve found over the past few days that a few seconds of explanation is enough to curb a patient’s desire for un-needed antibiotics. It’s easy to write a Rx for Azithromycin to make a patient happy. But judicious, evidence-based use of antibiotics will help contain health-care costs, prevent adverse side effects and slow antibiotic resistance rates. Antibiotic stewardship is a job for all of us!
Patrick Corey @pcoreyEM
1. Zoorob R, Mohamad SA, Fremont RD, Kihlberg C. Antibiotic Use in Acute Upper Respiratory Tract Infections. Am Fam Physician. 2012;86(9):817-822
2. Gill JM, Fleischut P, Haas S, Pellini B, Crawford A, Nash DB. Use of antibiotics for adult upper respiratory infections in outpatient settings: a national ambulatory network study. Fam Med. 2006;38(5):349-354.
3. Williams JW Jr, Aguilar C, Cornell J, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. 2008;(2):CD000243
4. Reveiz L, Cardona AF, Ospina EG. Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev. 2007;(2):CD004783.
5. Gonzales R, Bartlett JG, Besser RE, et al.; American Academy of Family Physicians; American College of Physicians-American Society of Internal Medicine; Centers for Disease Control; Infectious Diseases Society of America. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med. 2001;134(6):521-529.
6. National Institute for Health and Clinical Excellence. Respiratory tract infections—antibiotic prescribing. http://www.nice.org.uk/nicemedia/ live/12015/41323/41323.pdf. Accessed August 14, 2012.
7. Smucny J, Fahey T, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2004;(4):CD000245.