Professional Documents
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Background: Acute respiratory tract infection (ARTI) is the most example, persistent fevers, anterior cervical adenitis, and
common reason for antibiotic prescription in adults. Antibiotics tonsillopharyngeal exudates or other appropriate combination of
are often inappropriately prescribed for patients with ARTI. This symptoms) by rapid antigen detection test and/or culture for
article presents best practices for antibiotic use in healthy adults group A Streptococcus. Clinicians should treat patients with anti-
(those without chronic lung disease or immunocompromising biotics only if they have conrmed streptococcal pharyngitis.
conditions) presenting with ARTI.
High-Value Care Advice 3: Clinicians should reserve antibiotic
Methods: A narrative literature review of evidence about appro-
treatment for acute rhinosinusitis for patients with persistent
priate antibiotic use for ARTI in adults was conducted. The most
symptoms for more than 10 days, onset of severe symptoms or
recent clinical guidelines from professional societies were com-
signs of high fever (>39 C) and purulent nasal discharge or facial
plemented by meta-analyses, systematic reviews, and random-
pain lasting for at least 3 consecutive days, or onset of worsening
ized clinical trials. To identify evidence-based articles, the
Cochrane Library, PubMed, MEDLINE, and EMBASE were symptoms following a typical viral illness that lasted 5 days that
searched through September 2015 using the following Medical was initially improving (double sickening).
Subject Headings terms: acute bronchitis, respiratory tract in-
High-Value Care Advice 4: Clinicians should not prescribe
fection, pharyngitis, rhinosinusitis, and the common cold.
antibiotics for patients with the common cold.
High-Value Care Advice 1: Clinicians should not perform test-
ing or initiate antibiotic therapy in patients with bronchitis unless
pneumonia is suspected.
Ann Intern Med. 2016;164:425-434. doi:10.7326/M15-1840 www.annals.org
High-Value Care Advice 2: Clinicians should test patients with For author afliations, see end of text.
symptoms suggestive of group A streptococcal pharyngitis (for This article was published at www.annals.org on 19 January 2016.
* This paper, written by Aaron M. Harris, MD, MPH; Lauri A. Hicks, DO; and Amir Qaseem, MD, PhD, MHA, was developed for the High Value Care Task Force
of the American College of Physicians and for the Centers for Disease Control and Prevention. Individuals who served on the High Value Care Task Force from
initiation of the project until its approval were Amir Qaseem, MD, PhD, MHA (Chair); John Biebelhausen, MD, MBA; Sanjay Desai, MD; Lawrence Feinberg, MD;
Carrie A. Horwitch, MD, MPH; Linda L. Humphrey, MD, MPH; Robert M. McLean, MD; Tanveer P. Mir, MD; Darilyn V. Moyer, MD; Kelley M. Skeff, MD, PhD;
Thomas G. Tape, MD; and Jeffrey Wiese, MD. Approved by the ACP Board of Regents on 19 October 2015.
www.annals.org Annals of Internal Medicine Vol. 164 No. 6 15 March 2016 425
In 2009, direct antibiotic prescription costs totaled This article was reviewed and approved by the
$10.7 billion; 62% of these costs ($6.5 billion) were at- Centers for Disease Control and Prevention and by the
tributed to antibiotic prescribing in the community set- ACP High Value Care Task Force, whose members are
ting, followed by $3.6 billion in hospitals and $527 mil- physicians trained in internal medicine and its subspe-
lion in nursing homes and long-term care facilities (6). cialties and which includes experts in evidence synthe-
An estimated 50% of antibiotic prescriptions may be sis. The Task Force developed the high-value care ad-
unnecessary or inappropriate in the outpatient setting vice statements, which are summarized in the Figure,
(7) (Unpublished data. Centers for Disease Control and based on the narrative review of the literature. At each
Prevention), which equates to more than $3 billion in conference call, all members of the High Value Care
excess costs. Over the past decade, antibiotic prescrip- Task Force declared all nancial and nonnancial
tions have decreased by 18% among persons aged 5 interests.
years or older in the United States; however, prescrip-
tions for broad-spectrum antibiotics (uoroquinolones
and macrolides) have increased by at least 4-fold (8). ACUTE UNCOMPLICATED BRONCHITIS
Reducing inappropriate antibiotic prescribing in the Acute uncomplicated bronchitis is dened as a self-
ambulatory setting is a public health priority. limited inammation of the large airways (bronchi) with
This article by the American College of Physicians a cough lasting up to 6 weeks. The cough may or may
(ACP) and the Centers for Disease Control and Preven- not be productive (24) and is often accompanied by
tion presents available evidence on the appropriate mild constitutional symptoms. Acute bronchitis is
prescribing of antibiotics for adult patients with ARTI. among the most common adult outpatient diagnoses,
The high-value care advice is intended to amplify rather with about 100 million (10%) ambulatory care visits in
than replace messages from recent clinical guidelines the United States per year (8), more than 70% of which
on appropriate antibiotic prescribing (9 19) and serves result in a prescription for antibiotics (25, 26). Acute
as an update of the 2001 Principles of Appropriate An- bronchitis leads to more inappropriate antibiotic pre-
tibiotic Use for Treatment of Acute Respiratory Tract In- scribing than any other ARTI syndrome in adults (8).
fections in Adults (9) and a complement to the pediatric Determining the Likelihood of a Bacterial
principles published in 2013 (20). The target audience Infection
for this article is all clinicians providing care to adults
More than 90% of otherwise healthy patients pre-
seeking ambulatory care for ARTI.
senting to their outpatient providers with an acute
cough have a syndrome caused by a virus (Table) (10,
21, 22). Nonviral pathogens, such as Mycoplasma
METHODS pneumoniae and Chlamydophila pneumoniae, are oc-
casionally identied in patients with acute bronchitis
We conducted a narrative review of evidence
(10), and Bordetella pertussis may be considered in sit-
about appropriate antibiotic use for treatment of pa-
uations where transmission in the community has been
tients with ARTI syndromes, including acute uncompli-
reported. However, determining whether a patient has
cated bronchitis, pharyngitis, rhinosinusitis, and the
a viral or nonviral cause can be difcult. The presence
common cold. We included current clinical guidelines
of purulent sputum or a change in its color (for exam-
from leading professional societies, such as the Infec-
ple, green or yellow) does not signify bacterial infec-
tious Diseases Society of America (IDSA). Clinical
tion; purulence is due to the presence of inammatory
guideline recommendations were augmented with
cells or sloughed mucosal epithelial cells. Acute bron-
evidence-based meta-analyses, systematic reviews, and
chitis must be distinguished from pneumonia. For
randomized clinical trials. To identify these evidence-
healthy immunocompetent adults younger than 70
based articles, we conducted literature searches in the
years, pneumonia is unlikely in the absence of all of the
Cochrane Library, PubMed, MEDLINE, and EMBASE
following clinical criteria: tachycardia (heart rate >100
through September 2015. We included only English-
beats/min), tachypnea (respiratory rate >24 breaths/
language articles and used the following Medical Sub-
min), fever (oral temperature >38 C), and abnormal
ject Headings terms: acute bronchitis, respiratory
ndings on a chest examination (rales, egophony, or
tract infection, pharyngitis, rhinosinusitis, and the
tactile fremitus) (10, 27).
common cold. The focus of the article was limited to
healthy adults without chronic lung disease (such as Appropriate Management Strategies
cystic brosis, bronchiectasis, and chronic obstructive The most recent clinical guidelines for manage-
pulmonary disease) or immunocompromising condi- ment of acute uncomplicated bronchitis recommended
tions (congenital or acquired immunodeciencies, HIV against routine antibiotic treatment in the absence of
infection, chronic renal failure, nephrotic syndrome, pneumonia (11). A systematic review of 15 randomized,
leukemia, lymphoma, Hodgkin disease, generalized controlled trials found limited evidence to support the
cancer, multiple myeloma, iatrogenic immunosuppres- use of antibiotics for acute bronchitis and a trend to-
sion, or a history of solid organ transplantation). We ward increased adverse events in patients treated with
present our ndings for 4 ARTI syndromes and present antibiotics (28). A randomized, placebo-controlled trial
a framework for antibiotic prescribing strategies for (not included in the Cochrane review) comparing
each (Table). ibuprofen, amoxicillin clavulanic acid, and placebo
426 Annals of Internal Medicine Vol. 164 No. 6 15 March 2016 www.annals.org
Table. Antibiotic Prescribing Strategies for Adult Patients With Acute Respiratory Tract Infection
Harms of using Mild reactions: diarrhea Mild reactions: diarrhea and rash Mild reactions: diarrhea and rash Mild reactions: diarrhea
antibiotics and rash Severe reactions: Severe reactions: StevensJohnson and rash
Severe reactions: StevensJohnson syndrome syndrome Severe reactions:
StevensJohnson Severe infection: Clostridium Severe infection: Clostridium StevensJohnson
syndrome difcileassociated diarrhea difcileassociated diarrhea syndrome
Severe infection: Life-threatening reactions: Life-threatening reactions: Severe infection:
Clostridium anaphylactic shock and sudden anaphylactic shock and sudden Clostridium
difcileassociated cardiac death cardiac death difcileassociated
diarrhea diarrhea
Life-threatening Life-threatening
reactions: reactions: anaphylactic
anaphylactic shock shock and sudden
and sudden cardiac cardiac death
death
Antibiotic prescribing In the absence of Prescribe antipyretics and Antibiotics may be prescribed if Antibiotics should not be
strategy pneumonia, analgesics. symptoms last >10 d, severe used.
antibiotics are not -Lactam antibiotics are indicated symptoms last for >3 consecutive
indicated. with positive results on a days, or worsening symptoms last
Routine testing for streptococcal test. after 3 consecutive days.
nonviral causes is not
recommended.
Recommended
antibiotic
regimen
Persons without Never indicated 1) Oral penicillin V, 250 mg 4 1) Oral amoxicillin, 500 mg, and Never indicated
penicillin allergy times daily or 500 mg twice clavulanate, 125 mg, 3 times daily
daily for 10 d for 5 to 7 d
2) Oral amoxicillin, 50 mg/kg of 2) Oral amoxicillin, 875 mg, and
body weight (maximum, 1000 clavulanate, 125 mg, twice daily
mg) once daily or 25 mg/kg for 5 to 7 d
(maximum, 500 mg) twice daily 3) Oral amoxicillin, 500 mg 3 times
for 10 d daily for 5 to 7 d
3) Intramuscular benzathine
penicillin G, single dose of
1 200 000 U
Continued on following page
www.annals.org Annals of Internal Medicine Vol. 164 No. 6 15 March 2016 427
TableContinued
Figure. 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.
SUMMARY OF THE AMERICAN COLLEGE OF PHYSICIANS AND CENTERS FOR DISEASE CONTROL AND PREVENTION ADVICE FOR HIGH-VALUE CARE
ON APPROPRIATE ANTIBIOTIC USE FOR ACUTE RESPIRATORY TRACT INFECTION IN ADULTS
Harms of Using Antibiotics Annual direct costs are $6.5 billion and annual indirect costs are >$30 billion in the United States.
Antibiotics are responsible for 1 of every 5 emergency department visits for drug-related complications.
Complications occur in 5% to 25% of patients who use antibiotics.
Antibiotic-associated diarrhea caused by Clostridium difficile is the most common serious complication,
responsible for 29 300 deaths in the United States per year.
Approaches to Overcome Barriers to Multidimensional approaches involving active clinician education work best to reduce antibiotic
Evidence-Based Practice prescriptions, including physician and patient education, physician audit and feedback, delayed
antibiotic prescriptions, health information technology, and financial or regulatory incentives.
Talking Points for Clinicians When Discussing The average adult has 2 to 3 episodes of ARTI per year.
the Use of Antibiotics in Patients With ARTI Symptoms usually resolve in 1 to 2 weeks, but cough can last up to 6 weeks.
Symptomatic treatment tailored to patient preferences may provide relief.
Antibiotics do not cure most ARTIs or reduce time to resolution of symptoms.
Antibiotics cause many serious adverse effects and should be reserved for patients with confirmed
group A streptococcal pharyngitis.
High-Value Care Advice 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).
High-Value Care Advice 4: Clinicians should not prescribe antibiotics for patients with the common
cold.
www.annals.org Annals of Internal Medicine Vol. 164 No. 6 15 March 2016 429
antibiotics shorten the duration of sore throat by 1 to 2 cosal clearance as a result of a viral upper respiratory
days, but the benet is modest and the number tract infection (URI). Fewer than 2% of viral URIs Al-
needed to treat to reduce symptoms is 6 after 3 days of thoughare complicated by ABRS (14). The gold stan-
treatment and 21 after 1 week of treatment (40). Evi- dard for diagnosis of bacterial sinusitis is sinus punc-
dence suggests that antibiotics may prevent complica- ture with aspiration of purulent secretions, although it is
tions from group A streptococcal infection, including rarely performed. Common bacteria isolated from sinus
acute rheumatic fever (which is more common in chil- puncture are listed in the Table. Radiographic imaging
dren and adolescents than adults), peritonsillar ab- has no role in ascertaining a bacterial cause (14, 44).
scess, and further spread of group A Streptococcus in radiologic ndings, such as mucous membrane thick-
outbreaks (40). However, little evidence supports the ening or sinus uid or opacity, have a sensitivity of 90%
prevention of acute glomerulonephritis (40). Antibiotics in detecting a bacterial cause, the specicity is only
are not recommended for chronic group A Streptococ- 61% (44). Imaging is not helpful in guiding treatment
cus carriers because they are unlikely to spread infec- because viral and bacterial causes have similar radio-
tion to close contacts and are at little or no risk for logic features, and it would increase costs by at least
complications. Tonsillectomy solely to reduce the fre- 4-fold (44).
quency of group A streptococcal pharyngitis in adults is Because ABRS lacks a simple and accurate diag-
not recommended (13). nostic test, clinical guidelines recommend using clinical
Adult patients with sore throat should be offered signs and symptoms to differentiate bacterial from viral
analgesic therapy, such as aspirin, acetaminophen, causes (15). A bacterial cause is more likely when symp-
nonsteroidal anti-inammatory drugs, and throat loz- toms persist for more than 10 days without clinical im-
enges, which can help reduce pain. Salt water, viscous provement, symptoms are severe (fever >39 C, puru-
lidocaine, and other mixtures are often used in clinical lent nasal discharge, or facial pain lasting for >3
practice for topical pain relief, but there are few data consecutive days), or symptoms worsen after an initial
examining these approaches. Patients can be assured period of improvement (double sickening) for more
that the typical course of a sore throat is less than 1 than 3 days. In addition, a patient with new-onset fever,
week and that antibiotics are usually not needed be- headache, or increased nasal discharge after a typical
cause they do little to alleviate symptoms and may have viral URI that was initially improving is suspicious for a
adverse effects (12, 13, 40). bacterial cause.
High-Value Care Advice 2
Appropriate Management Strategies
Clinicians should test patients with symptoms sug-
The 2012 IDSA clinical practice guidelines recom-
gestive of group A streptococcal pharyngitis (for exam-
mend empirical antibiotics as soon as a clinical diagno-
ple, persistent fevers, anterior cervical adenitis, and
sis of ABRS is established on the basis of clinical criteria
tonsillopharyngeal exudates or other appropriate com-
(15). Amoxicillin clavulanate is the preferred agent,
bination of symptoms) by rapid antigen detection test
and doxycycline or a respiratory uoroquinolone may
and/or culture for group A Streptococcus. Clinicians
be used as an alternative in patients with ABRS. The
should treat patients with antibiotics only if they have
American Academy of OtolaryngologyHead and Neck
conrmed streptococcal pharyngitis.
Surgery emphasizes watchful waiting (without antibiotic
therapy) as initial management for all patients with un-
ACUTE RHINOSINUSITIS complicated ABRS, regardless of severity (16). Some
Acute rhinosinusitis is usually a self-limited illness professional societies, including the American Acad-
resulting from a viral infection, allergy, or irritant that emy of Allergy, Asthma & Immunology and the Ameri-
causes inammation of the mucosal tissue in the nasal can Academy of Family Physicians, recommend amoxi-
and paranasal sinus cavity. Clinical symptoms include cillin as the preferred agent (17, 18). Although the IDSA
nasal congestion and obstruction, purulent nasal dis- recommendation is based on concern for antibiotic re-
charge, maxillary tooth pain, facial pain or pressure, fe- sistance, specically ampicillin-resistant Haemophilus
ver, fatigue, cough, hyposmia or anosmia, ear pressure inuenzae and Moraxella catarrhalis, no direct evidence
or fullness, headache, and halitosis. Symptom duration suggests that amoxicillin clavulanate is superior. Ad-
ranges from 1 to 33 days, with most episodes resolving junctive therapy, such as intranasal saline irrigation or
within a week (41). More than 4.3 million adults are intranasal corticosteroids, has been shown to alleviate
diagnosed with sinusitis annually, and more than 80% symptoms and potentially decrease antibiotic use (15).
of ambulatory care visits result in an antibiotic prescrip- Patients who are seriously ill, who deteriorate clinically
tion, most commonly a macrolide (42). Most antibiotic despite antibiotic therapy, or who have recurrent epi-
prescriptions for this condition are unnecessary (43). sodes should be referred to a specialist (for example,
an otolaryngologist, infectious disease specialist, or al-
Determining the Likelihood of a Bacterial lergist) (15).
Infection Acute uncomplicated rhinosinusitis is a self-limited
Acute rhinosinusitis is usually caused by a viral infection that usually resolves without antibiotics, even
pathogen. Acute bacterial rhinosinusitis (ABRS) is con- in patients with a bacterial cause. Most patients diag-
sidered to be a secondary infection resulting from ob- nosed with acute rhinosinusitis have more adverse ef-
struction of the sinus ostia that leads to impaired mu- fects than benets from antibiotics (45). A meta-analysis
430 Annals of Internal Medicine Vol. 164 No. 6 15 March 2016 www.annals.org
with the patient to explain the patient's illness, than on Disclosures: Dr. Moyer reports that she is Chair of the Board
the receipt of an antibiotic prescription (61). of Governors of the American College of Physicians. Authors
To increase patient satisfaction and decrease anti- not named here have disclosed no conicts of interest. Disclo-
biotic prescriptions for ARTI, we offer the following sures can also be viewed at www.acponline.org/authors/icmje
evidence-based strategies. Clinicians can promote ap- /ConictOfInterestForms.do?msNum=M15-1840. Any nan-
propriate antibiotic use by labeling acute bronchitis as cial and nonnancial conicts of interest of the group
a chest cold or viral upper respiratory infection (62) members were declared, discussed, and resolved. A record of
and providing patient information sheets about appro- disclosures of interest is kept for each High Value Care Task
Force meeting and conference call and can be viewed at http:
priate antibiotic use and alternatives to antibiotics for
//hvc.acponline.org/clinrec.html.
managing symptoms (www.cdc.gov/getsmart) (63). A
recent study showed an 85% decrease in antibiotic pre-
scribing for ARTI and increased satisfaction ratings Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA,
when providers gave advice on symptomatic therapy American College of Physicians, 190 N. Independence Mall
and explained why antibiotics were not needed for West, Philadelphia, PA 19106; e-mail, aqaseem@acponline
ARTI (64). A symptomatic prescription pad can be used .org.
to provide recommendations for management of
symptoms, allowing patients to walk away with a plan of Current author addresses and author contributions are avail-
action (Supplement, available at www.annals.org). able at www.annals.org.
When it is unclear whether an antibiotic is needed, de-
layed or postdated antibiotic prescriptions (also known
as the wait-and-see approach) offer the possibility of References
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