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June
2007: VOLUME
1, NUMBER 1
Welcome...
The
Johns Hopkins University School of Medicine is pleased to welcome you
to this inaugural issue of eInfections Review. Over
the course of this series, we will be reporting on issues critical to
providing the safest and most effective care for patients presenting
with infectious or parasitic diseases.
To receive CE credit: after reading
the newsletter, please follow the instructions on the right side of
this page to complete your Post Test and Evaluation.
If you find the information presented
in this series valuable, please recommend eInfections Review to
your colleagues. The easiest way to do so is by viewing
this page or via the links above.
In
This Issue...
Upper Respiratory Tract Infections
Sinusitis, pharyngitis, and acute
bronchitis are three of the most common infections encountered in clinical
practice. They are also three of the most challenging in terms of management
decisions for diagnosis, treatment, and particularly antibiotic usage.
How should the decision to treat or test be made? Which agents, if any,
should be prescribed? What outcomes can be expected in which populations?
In this issue we report on the
current research addressing these upper respiratory infection management
concerns. |
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Course
Directors
John
G. Bartlett, MD
Professor of Medicine
Department of Medicine
The Johns Hopkins
University
School of Medicine
Baltimore, MD
Paul
G. Auwaerter, MD
Associate Professor
of Medicine
Clinical Director
Division of Infectious
Diseases
The Johns Hopkins
University
School of Medicine
Baltimore, MD
Sara
E. Cosgrove, MD, MS
Assistant Professor
of Medicine
Division of Infectious
Diseases
Director
Antibiotic Management
Program
Associate Hospital
Epidemiologist
The Johns Hopkins
University
School of Medicine
Baltimore, MD |
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GUEST
AUTHORS OF THE MONTH |
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Commentary
& Reviews: |
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John
G. Bartlett, MD
Professor
of Medicine
Department
of Medicine
The Johns
Hopkins University
School
of Medicine
Baltimore,
MD |
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Commentary
& Reviews: |
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Paul
G. Auwaerter, MD
Associate
Professor of Medicine
Clinical
Director
Division
of Infectious Diseases
The Johns
Hopkins University
School
of Medicine
Baltimore,
MD |
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Commentary
& Reviews:
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Sara
E. Cosgrove, MD, MS
Assistant
Professor of Medicine
Division
of Infectious Diseases
Director
Antibiotic
Management Program
Associate
Hospital Epidemiologist
The Johns
Hopkins University
School
of Medicine
Baltimore,
MD |
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Guest
Faculty Disclosures
John
G. Bartlett, MD, has disclosed that he has served on the
HIV Advisory Board for GlaxoSmithKline, Abbott, Bristol-Myers Squibb,
Pfizer and Tibotec. He is also on the Policy Board for Johnson & Johnson.
Paul
G. Auwaerter, MD, has disclosed that he has served as a consultant
for Novartis, Pfizer, Ortho-McNeil, Schering-Plough, and Genzyme.
He is on the Speaker Bureau for Schering-Plough and has also disclosed
that he is a Stock Shareholder for Johnson and Johnson.
Sara
E. Cosgrove, MD, MS, has disclosed that as a co-investigator,
she has received grants or research support from Merck and served
on the Advisory Boards for Ortho-McNeil and Cadence Pharmaceuticals.
Unlabeled / Unapproved Uses
The authors have
indicated that there are no references to unlabeled/ unapproved uses
of drugs or products in this presentation. |
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the conclusion of this activity, participants should be able to: |
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Integrate
into practice the new diagnostic techniques and treatment protocols
presented in the program |
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Recognize
and incorporate into practice the effects of emerging drug resistance |
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Identify
and incorporate into practice the public health imperative for a
comprehensive treatment strategy across a wide spectrum of communicable
diseases |
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Acute
sinusitis is one of the most common conditions managed in primary care.
Although current guidelines recommend using antibiotics only if a bacterial
pathogen is suspected and only after patients have failed supportive
measures after 7 to 10 days, acute sinusitis accounts for 21% of all
antibiotic prescriptions in adults, indicating that antibiotics are
overused in this syndrome[1]. The studies reviewed herein
further support the idea that the majority of cases of acute sinusitis
do not require antibiotic therapy. Merenstein et al found no significant
difference in improvement rates between amoxicillin vs placebo, as
well as no difference in patients’ rating of illness severity. While
it is possible that if the sample size were greater, the difference
between the amoxicillin arm (48%) and the placebo arm (37%) would have
been significant, the overall percentage of patients who might gain
this benefit would likely remain low.
While the study by Meltzer et
al does not show a difference in symptom scores in a similar group of
patients with at least 7 days of symptoms who are treated with amoxicillin
or placebo, it does demonstrate a significant difference in symptom
scores in patients who receive intranasal steroids. A recent Cochrane
Review found that intranasal steroids may contribute to earlier improvement
and faster resolution of symptoms[2], although this is the
first study to demonstrate the benefit of intranasal steroids as monotherapy
for acute sinusitis.
The rationale to treat Group
A streptococcal (GAS) pharyngitis with antibiotics has been historically
grounded in the prevention of acute rheumatic fever, which has essentially
vanished as an affliction of adults in developed countries. At best,
antibiotics prescribed for GAS pharyngitis result in a 16 hour shorter
duration of symptoms, although they do reduce the incidence of uncommon
suppurative complications such as sinusitis or peritonsillar abscess[3].
Despite these issues, pharyngitis remains one of the most common illnesses
prompting office visits for primary care providers and pediatricians.
The study by St Sauvin et al on recurrent strep should be of particular
interest to the latter: although only a relatively small percentage
of children were afflicted with recurrences, the authors argue that
on a population basis, this finding actually represents a substantial
number of children.
Since viruses cause the majority
of adult pharyngitis, both the Infectious Diseases Society of America
(IDSA)[4] and the American College of Physicians—American
Society of Internal Medicine (ACP-ASIM)[5] recommend to neither
test nor treat mild pharyngitis as defined by the Centor scoring system
of 0 or 1 (one point each for history of fever, lack of cough, enlarged/tender
anterior cervical lymphadenopathy and tonsillar exudates). The guidelines
do differ for more severe pharyngitis, with IDSA recommending antibiotic
therapy only for patients with positive rapid Group A streptococcal
testing, while ACP-ASIM suggests empiric therapy for patients with scores
of 3 or 4. The report by Linder at al (reviewed herein) found non-adherence
to any of these guidelines in 66% of office visits. Another study prospectively
examining these different strategies found that the specificity using
clinical criteria (modified Centor score of 3 or 4 in adults) was only
43.8% for GAS-related pharyngitis[6]. Moreover, unnecessary
prescriptions were judged to be highest in the group diagnosed empirically
(45.7%) compared to those treated based upon the results of rapid testing
(24.7%), suggesting that, compared to relying solely on clinical criteria,
following the IDSA guideline results in lower antibiotic prescribing.
As supported by both the Wenzel & Fowler New England Journal of Medicine
article, and the study by Mainous
et al, acute bronchitis is possibly
the "king" of
all clinical examples of antibiotic
abuse in the sense that it is
common practice to prescribe
when other antibacterial agents
are rarely indicated. The major
exception is influenza, which
can be proven with the rapid
influenza test (sensitivity of
70%), and, if caught early, can be treated with oseltamivir or zanamivir
within 48 hours of onset of symptoms. The other treatable pathogen is Bordetella
pertussis, which
is relatively uncommon, but should
be considered in the patient
with a paroxysmal cough that
persists for weeks. The major
condition to exclude in patients
with acute bronchitis is community-acquired
pneumonia (CAP): abnormal vital
signs or rales are the key indicators
that should lead the clinician to order a chest x-ray.
The unifying concept in these
three conditions is the fact that most are caused by viral infections
that do not benefit from antibacterial treatment. Diagnostic testing
is of little use in the majority of presentations: the notable exceptions
are the rapid strep antigen test in patients that have pharyngitis and
the rapid influenza test in patients with typical flu symptoms in the
presence of an influenza epidemic. Both tests are generally available
for use in office practice and both can be used for therapeutic decisions.
The widespread use of antibacterial agents for these conditions is to
be discouraged, although there are exceptions with all three.
References
| 1. |
Sinus
and Allergy Health Partnership. Antimicrobial
treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol
Head Neck Surg. 2004;130:S1-S45. |
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| 2. |
Zalmanovici
A, Yaphe J. Steroids
for acute sinusitis. Cochrane Database of Systematic Reviews.
2007, Issue 2. Art. No. CD005149. |
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| 3. |
Del
Mar CB, Glasziou PP, Spinks AB. Antibiotics
for sore throat. Cochrane Database of Systematic Reviews.
2006, Issue 4. Art. No.: CD000023. DOI:10.1002/14651858. CD000023.pub3. |
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| 4. |
Bisno
AL, Gerber MA, Gwaltney JM, Jr., et al. Practice
guidelines for the diagnosis and management of group A streptococcal
pharyngitis. Infectious Diseases Society of America. Clin
Infect Dis. 2002;35:113-25. |
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| 5. |
Cooper
RJ, Hoffman JR, Bartlett JG, et al. Principles
of appropriate antibiotic use for acute pharyngitis in adults: background. Ann
Intern Med. 2001;134:509-17. |
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| 6. |
McIsaac
WJ, Kellner JD, Aufricht P, et al. Empirical
validation of guidelines for the management of pharyngitis in children
and adults. JAMA. 2004;291:1587-95. |
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ACUTE
SINUSITIS: THE ROLE OF ANTIBIOTICS |
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Merenstein
D, Whittaker C, Chadwell T, Wegner B, D’Amico F. Are
antibiotics beneficial for patients with sinusitis complaints?
A randomized double-blind clinical trial. J Fam
Pract. 2005;54:144-151.
(For non-journal subscribers, an additional fee may apply
for full text articles.) |
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Merenstein
et al performed a prospective, randomized, double-blind, placebo
controlled trial of amoxicillin 1g orally twice daily for 10 days
vs placebo in the treatment of acute sinusitis in adults ≥18 years.
Patients had to have symptoms for at least seven days, and show at
least one cardinal clinical feature of bacterial sinusitis: 1) purulent
nasal discharge predominating on one side, 2) local facial pain predominating
on one side, 3) purulent nasal discharge on both sides, or 4) pus
in the nasal cavity. Patients were excluded if they had received
antibiotics in the past month, were penicillin allergic, were immunocompromised,
had concomitant pneumonia or streptococcal pharyngitis, or had a
history of sinus surgery. Follow-up telephone interviews were conducted
on days 3, 7, and 14 to assess for clinical improvement. The primary
outcome measures were resolution of symptoms by the end of two weeks,
and time to improvement.
One hundred and thirty
five patients were randomized to amoxicillin (n = 67) or placebo
(n = 68). Patients had a mean of 11 days of symptoms prior to enrollment.
About 1/3 of patients had 3-4 cardinal symptoms. At two weeks, there
was no significant difference in rates of improvement in the two
groups: 32 (48%) in the amoxicillin arm and 25 (37%) in the placebo
arm (RR for failure 1.3, 95% CI 0.87-1.94). In addition, there were
no differences in patients’ ratings of how sick they felt on days
0, 3, 7, and 14 in either arm. However, patients in the amoxicillin
arm had a significantly faster time to improvement than those in
the placebo arm (p = .04). Among patients who experienced complete
recovery (n = 57), the median time to any improvement was 8 days
for the amoxicillin arm vs 12 days for the placebo arm (p = .005).
There was no correlation between the number of signs and symptoms
and days to improvement in either arm of the study.
This study suggests
that the use of antibiotics provides only minimal benefit in the
management of most cases of acute sinusitis that have persisted for
at least 7 days. However, among patients with complete improvement,
there is a subgroup of patients in whom amoxicillin therapy decreased
signs and symptoms by 2-3 days relative to placebo. Unfortunately,
the number of cardinal symptoms was not helpful in distinguishing
which patients would respond. Note that acute sinusitis was not rigorously
diagnosed using imaging or sinus puncture and culture as in some
previous studies; however, the clinical criteria used in this study
reflect those available to primary care practitioners. |
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ACUTE
SINUSITIS: THE ROLE OF INTRANASAL STEROIDS |
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Meltzer
EO, Bachert C, Staudinger H. Treating acute rhinosinusitis:
comparing efficacy and safety of mometasone furoate nasal spray,
amoxicillin, and placebo. J Allergy Clin Immunol.
2005;116:1289-95.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Meltzer
et al performed a prospective, randomized, double-blind, placebo controlled
trial of mometasone furoate nasal spray (MFNS) 200 mcg once daily vs.
twice daily vs amoxicillin 500 mg take three times daily for 10 days
vs placebo in the treatment of acute sinusitis in persons ≥ 12 years.
Patients had to have symptoms for between 7 and 28 days as well as a
major symptom score (MSS) between 5 and 12. MSS was the sum of scores
on a 0-3 scale (none to severe) for rhinorrhea, postnasal drip, nasal
congestion/stuffiness, sinus headache, facial pain, pressure, and/or
tenderness over paranasal sinuses. Patients were excluded if they had
signs and symptoms suggestive of fulminant bacterial rhinosinusitis,
if they had chronic rhinosinusitis, or if they were allergic to study
medications. Patients were monitored by telephone on days 3 to 4 and
treatment visits on days 8, 15, and 29. The primary efficacy endpoint
was mean MSS over days 2 to 15 of treatment.
Nine hundred eighty-one patients
were randomized to MFNS daily (n = 243), MFNS twice daily (n = 235),
amoxicillin (n = 251) or placebo (n = 252). Two thirds of patients had
6-14 days of symptoms prior to enrollment and one third had 15-28 days
of symptoms. The mean MSS at baseline was 8.17 to 8.53 across treatment
groups, indicative of mild to moderate disease. The mean MSS over days
2 to 15 of treatment was significantly lower in the MFNS twice daily
arm than in the amoxicillin arm (p = .002) or placebo arm (p < .001).
The mean MSS during this same period was significantly lower in the
MFNS daily arm than in the placebo arm (p = .018) but not the amoxicillin
arm (p = .19). There were no significant differences in recurrence rates
in the treatment groups.
This study suggests that intranasal
steroids may provide benefits similar to or better than antibiotics
in the management of acute sinusitis without exposing patients to the
risk of colonization or infection with resistant organisms, or putting
them at risk for recurrence of disease. It is the first study to assess
the benefit of intranasal steroids as monotherapy compared to placebo
rather than as an adjunct to antibiotic therapy. Higher doses of intranasal
steroids (mometasone furoate 200 mcg twice daily) provided greater benefit
relative to once daily dosing, as well as to amoxicillin therapy and
placebo. In addition, this study again demonstrates that in this population
of patients with mild to moderate acute sinusitis, no difference in
outcomes was seen in between patients receiving amoxicillin and those
receiving placebo. |
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ADULT
PHARYNGITIS: NONADHERENCE TO CLINICAL GUIDELINES IN PRIMARY CARE PRACTICE |
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Linder
JA, Chan JC, Bates DW. Evaluation and treatment of pharyngitis
in primary care practice: the difference between guidelines is largely
academic. Arch Intern Med. 2006 Jul 10;166(13):1374-9.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Linder
et al examined the practice patterns of primary care physicians in nine
Partners HealthCare Clinics in the Boston area for adults with pharyngitis.
Over two thousand visits were evaluated, retrospectively, to determine
whether physicians followed one of three recommended strategies:
ACP empirical strategy:
- Centor
scores of 0, 1, or 2 = no streptococcal testing and no antibiotics
prescribed
- Centor
3 or 4 = no streptococcal test performed but antibiotics prescribed
ACP
test strategy:
- Centor
0 or 1 = no streptococcal test performed and no antibiotics prescribed
- Centor
2 or 3 = subject to streptococcal testing with positive tests associated
with an antibiotic prescription
- Centor
4 criteria = no streptococcal test performed and an antibiotic prescribed
IDSA
strategy:
- Centor
0 or 1 = no test and no antibiotic
- Centor
2, 3 or 4 = considered candidates for streptococcal testing with
receipt of antibiotics for a positive test
As the findings above show, antibiotics
were prescribed to 47% of patients even though 80% of patients received
rapid streptococcal testing and a positive result was obtained in only
17%. Overall, patients clearly received more testing than warranted
by guidelines; further, they also received more antibiotics despite
the negative results of the excessive testing. Nonadherence to guidelines
was found in 66% of visits, with the most common reasons for nonadherence
found to be testing and antibiotic prescriptions given to patients at
low risk for streptococcal pharyngitis.
Given the retrospective nature
of the study, physicians may not have accurately documented the signs
and symptoms of pharyngitis. Moreover, the study was not done with a
gold standard test in each patient (streptococcal throat culture).
Regardless, the authors rightly
suggest that dickering over which guideline to follow is not important.
Rather, for physicians who fail to follow any of the guidelines, there
is great potential to reduce inappropriate streptococcal testing and
antibiotic prescribing by adoption of one guideline or another. |
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St
Sauver JL, Weaver AL, Orvidas LJ, Jacobson RM, Jacobsen SJ. Population-based
prevalence of repeated group A beta-hemolytic streptococcal pharyngitis
episodes. Mayo Clin Proc. 2006 Sep;81(9):1172-6.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Bisno
AL, Kaplan EL. Strep throat over and over: how frequent?
How real? Mayo Clin Proc. 2006;81:1153-4.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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View
journal abstract |
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View
full article |
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The
rate of streptococcal infection in children has routinely been found
to account for at least 15-30% of acute pharyngitis. Although usually
a benign illness, recurrent episodes of GAS (group A ß-hemolytic streptococcal)
pharyngitis may be especially costly in terms of high treatment costs,
lost guardian work productivity, and potential tonsillectomy. This study
by St Sauver et al was done to determine population-based prevalence
of repeated GAS pharyngitis, as little information exists on actual
rates.
The authors used the Olmsted
County, Minnesota linked medical record system to determine how commonly
recurrent streptococcal pharyngitis afflicts children between the ages
of 4-15 years of age. Cases were defined as evidence of a sore throat
accompanied by either a positive rapid streptococcal antigen test or
positive throat culture for GAS. Repeated GAS cases were defined using
the American Academy of Otolaryngology-Head and Neck Surgery 2000 guidelines
indicating that children with 3 or more infections of the tonsils/adenoids
per year were candidates for tonsillectomy. GAS pharyngitis recurring
within one month of a prior bout was judged as inadequate medical therapy
rather than a repeated case.
Key findings based upon age-specific
rates for all residents 4 to 15 years of age in Rochester, Minnesota
(1996-1998) were as follows:
Although only a relatively small
percentage of children were afflicted with recurrences, the authors
argue that on a population basis, this finding represents a substantial
number of children. They note that future studies on patients with recurrent
GAS pharyngitis should focus on yielding the highest benefit via reducing
episodes and trimming healthcare and productivity costs.
The accompanying editorial by
Alan Bisno of the University of Miami rightly points out that these
low rates may represent an overestimation, given the retrospective methodology
as well as GAS pharyngeal colonization rates that may be as high as
15% in school-aged children. Separation of streptococcal colonization
from actual infection may be difficult although children with cough,
hoarseness, conjunctivitis, diarrhea, or coryza are highly suggestive
of a viral process and therefore a positive strep test in this setting
may merely reflect colonization. Regardless, recent efforts at developing
a GAS vaccine, if successful, may prove to be of highest value to this
subset of patients and their parents. |
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ACUTE
BRONCHITIS: AN OVERVIEW |
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Wenzel
RP, Fowler AA. Clinical practice. Acute bronchitis. N
Engl J Med. 2006;355:2125-30.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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View
journal abstract |
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View
full article |
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The
authors provide a well-referenced scholarly review in this 2006 “Clinical
Practice” feature in the New England Journal of Medicine. Highlights
include:
Etiology: The most common causes of viral bronchitis
include influenza, parainfluenza, respiratory syncytial virus, coronavirus,
adenovirus, and rhinovirus. In some cases atypical bacteria including Bordetella
pertussis, Chlamydiophyla pneumoniae and Mycoplasma
pneumoniae are involved. The authors note that the number of cases
involving B. pertussis in patients with persistent cough (lasting
weeks or months) is highly variable in different studies.
Natural History: The typical case is a URI that is
associated with cough lasting more than five days. Forty percent of
patients have significant reduction in forced expiratory volume at one
second or bronchial hyperreactivity. The cough usually lasts 10-20 days,
with an average of 18 days in one large study of 2,781 patients[1].
About 50% of patients report purulent sputum, although this does not
indicate either pneumonitis or bacterial infection.
Diagnosis: One of the first diagnostic questions concerns
the need for a chest x-ray to rule out CAP or other pulmonary process.
Prior studies indicate this is generally unnecessary if vital signs
are normal and there are no rales on chest exam[2]. A possible
exception is cough in an elderly patient; for example, a study of patients
over 75 years of age with CAP showed only 30% had temperatures above
38°C, and only 37% had tachycardia exceeding 100/min[3].
With regard to microbiology, the recommendation from the American College
of Physicians are to avoid sputum cultures for bacterial pathogens since
they are often misleading[4]. Diagnostic tests for other
agents should be done, if available, and would detect a treatable agent.
This is most common with influenza, which should be suspected in any
patient who has a typical febrile illness during an influenza epidemic.
In these cases, a rapid test for influenza virus would be useful, since
treatment needs to be given within 48 hours of the onset of symptoms
to be useful (these tests show a sensitivity of about 70%).
Antimicrobial Therapy: This is not recommended in the
great majority of cases. A Cochrane Review of randomized, controlled
trials of antibiotics for acute bronchitis showed a reduction in the
duration of cough by an average of 0.6 days, which was statistically
significant, but not felt to be recommended because the minor benefit
of treatment vs the risk associated with antibiotic exposure in terms
of side effects, cost, and resistance[5]. Oseltamivir or
zanamivir have been shown to decrease the duration of symptoms by approximately
one day and return to normal activity by 0.5 days if given within 48
hours of the onset of flu symptoms[6]. It should be noted
that the benefit is substantially increased when one of these neuraminidase
inhibitors is given very early in the course. As noted, other treatable
pathogens include M pneumoniae or C pneumoniae, but
there is little evidence that antibiotic treatment is beneficial in
the absence of pneumonia. With regard to pertussis, a macrolide is advocated
to prevent transmission, but does not alter the natural history of the
infection.
Other Therapies: Several placebo-controlled trials
have examined the potential benefit of β2-agonists and shown minimal
benefit, even in patients with airflow obstruction[7]. A
brief (7 days) trial of inhaled or oral corticosteroids may be tried
in some patients with "troublesome cough," but there are no clinical
trial data to support this recommendation. There is also minimal support
for the use of mucolytic or antitussive agents.
References
| 1. |
Ward
JI, Cherry JD, Chang SJ, et a. Efficacy
of an acellular pertussis vaccine among adolescents and adults. N
Engl J Med. 2005;353:1555-63. |
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| 2. |
Metlay
JP, Kapoor WN, Fine MJ. Does
this patient have community-acquired pneumonia? Diagnosing pneumonia
by history and physical examination. JAMA. 1997;278:1440-5. |
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| 3. |
Metlay
JP, Schulz R, Li YH, Singer DE, Marrie TJ, Coley CM et al. Influence
of age on symptoms at presentation in patients with community-acquired
pneumonia. Arch Intern Med. 1997;157:1453-9. |
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| 4. |
Gonzales
R, Bartlett JG, Besser RE, et al. Principles
of appropriate antibiotic use for treatment of uncomplicated acute
bronchitis: background. Ann Intern Med. 2001;134:521-9. |
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| 5. |
Smucny
J, Fahey T, Becker L, et al. Antibiotics
for acute bronchitis. Cochrane Database Systematic Reviews.
2000;(4):CD00245. |
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| 6. |
Hayden
FG, Osterhaus AD, Treanor JJ, et al. Efficacy
and safety of the neuraminidase inhibitor zanamivir in the treatment
of influenza virus infections. GG167 Influenza Study Group. N
Engl J Med. 1997 Sep 25;337(13):874-80. |
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| 7. |
Smucny
J, Flynn C, Becker L, et al. Beta2-agonists
for acute bronchitis. Cochrane Database Systematic Reviews.
2006;(1):CD001726. |
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ACUTE
BRONCHITIS: AMBULATORY ANTIBIOTIC PRESCRIBING |
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Mainous
AG, Saxena S, Hueston WJ, et al. Ambulatory antibiotic prescribing
for acute bronchitis and cough and hospital admissions for respiratory
infections: time trends analysis. J R Soc Med. 2006;99:358-62.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Acute
bronchitis is one of the most common infections seen in primary care,
as well as a condition that is subject to substantial concerns regarding
the overuse of antibiotics. Mainous et al sought to determine the relationship
between antibiotic prescribing for acute bronchitis with hospitalization
for respiratory infections in the US for the period 1996-2003. Their
analysis was based on data from the National Ambulatory Medical Care
Survey and the National Hospital Ambulatory Medical Care Survey for
prescribing practices, and was limited to adults 18-64 years. The results
indicated total visits ranged from 5,687,503 in 1996 to 9,892,260 in
2003. The number of patients with the diagnosis of acute bronchitis
who received antibiotics ranged from a high of 73% in 1998 to a nadir
of 53% in 2001. The figure for 2003 was 65%.
It should be noted that the data
provided in this report are consistent with multiple other studies which
show that about 50-70% of patients with the diagnosis of acute bronchitis
who seek medical care receive an antibiotic despite a consistent recommendation
against this practice.
Important observations highlighted
in the report include:
- Nearly all cases are due to viral infections.
- The diagnostic evaluation is usually limited to decisions regarding
the need for a chest x-ray, the need for microbiology studies, and
treatment options. With regard to x-rays, the recommendation is to
order them only if there is evidence of other processes, primarily
pneumonia as indicated by rales or abnormal vital signs including
fever and/or tachypnea. Note that these guidelines do not always apply
with elderly patients, since they may have pneumonia that is much
less likely to show fever. The most commonly useful test for etiology
is the rapid influenza test, which is recommended if therapy is considered,
symptoms are typical, and there is influenza in the region.
- Antimicrobial agents are recommended for influenza (using oseltamivir
or zanamivir) if symptoms are less than 48 hours in duration; the
earlier these agents are prescribed, the better. Occasionally patients
with very prolonged cough have pertussis, which should be confirmed
and treated with a macrolide. However, the great majority of patients
with acute bronchitis who have an untreatable viral infection do not
benefit from antibacterial agents.
- The use of antibacterials is commonly viewed as one of the most
common abuses of antibiotics, and is potentially harmful due to resistance,
cost, and side effects. Surveys have shown that most physicians and
most patients equate "acute bronchitis" with the need for antibacterials
— this has led Ralph Gonzales et al to avoid that term and instead
call it a "chest cold"[1].
References
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| Accreditation
Statement — back
to top |
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| The
Johns Hopkins University School of Medicine is accredited by the
Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians. |
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| Credit
Designations — back
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Physicians
eNewsletter: The Johns Hopkins University School
of Medicine designates this educational activity for a maximum of
1.0 AMA PRA Category 1 Credit(s)TM. Physicians
should only claim credit commensurate with the extent of their participation
in the activity.
Podcast: The Johns Hopkins University School of
Medicine designates this educational activity for a maximum of 0.5 AMA
PRA Category 1 Credit(s)TM. Physicians should only
claim credit commensurate with the extent of their participation
in the activity. |
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| Post-Test
— back
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| To
take the post-test for eInfections Review Review you will need to
visit The
Johns Hopkins University School of Medicine's CME website. If
you have already registered for another Hopkins CME program at these
sites, simply enter the requested information when prompted. Otherwise,
complete the registration form to begin the testing process. A passing
grade of 70% or higher on the post test/evaluation is required to
receive CME credit. |
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| Statement
of Responsibility — back
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| The
Johns Hopkins University School of Medicine takes responsibility
for the content, quality, and scientific integrity of this CME activity. |
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| Target
Audience — back
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| This
activity has been developed for the Primary Care Physician, Internist,
and Infectious Disease Specialist. |
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| Learning
Objectives — back
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At
the conclusion of this activity, participants should be able to:
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Describe
the proper use of antibiotic agents in treating upper respiratory
infections |
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Discuss
diagnostic strategies for evaluating the severity of upper respiratory
infections |
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Evaluate
how the data presented may best be integrated into current clinical
practice |
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| Internet
CME Policy — back
to top |
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| The
Office of Continuing Medical Education (CME) at The Johns Hopkins
University School of Medicine is committed to protect the privacy
of its members and customers. Johns Hopkins University SOM CME maintains
its Internet site as an information resource and service for physicians,
other health professionals and the public. Continuing Medical Education
at The Johns Hopkins University School of Medicine will keep your
personal and credit information confidential when you participate
in a CME Internet based program. Your information will never be
given to anyone outside of the Johns Hopkins University School of
Medicine's CME program. CME collects only the information necessary
to provide you with the services that you request. |
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| Faculty
Disclosure — back
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As
a provider accredited by the Accreditation Council for Continuing
Medical Education (ACCME), it is the policy of Johns Hopkins University
School of Medicine to require the disclosure of the existence of
any significant financial interest or any other relationship a faculty
member or a provider has with the manufacturer(s) of any commercial
product(s) discussed in an educational presentation. The presenting
faculty reported the following:
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John
G. Bartlett, MD, has disclosed that he has served on
the HIV Advisory Board for GlaxoSmithKline, Abbott, Bristol-Myers
Squibb, Pfizer and Tibotec. He is also on the Policy Board for
Johnson & Johnson. |
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Paul
G. Auwaerter, MD, has disclosed that he has served
as a consultant for Novartis, Pfizer, Ortho-McNeil, Schering-Plough,
and Genzyme. He is on the Speaker Bureaus' for Schering-Plough
and has also disclosed that he is a Stock Shareholder for Johnson
& Johnson. |
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Sara
E. Cosgrove, MD, MS, has disclosed that as a co-investigator,
she has received grants or research support from Merck and served
on the Advisory Boards for Ortho-McNeil and Cadence Pharmaceuticals. |
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| Disclaimer
Statement — back
to top |
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| The
opinions and recommendations expressed by faculty and other experts
whose input is included in this program are their own. Use of The
Johns Hopkins University School of Medicine name implies review
of educational format design and approach. Please review the complete
prescribing information of specific drugs or combination of drugs,
including indications, contraindications, warnings and adverse effects
before administering pharmacologic therapy to patients. |
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COMPLETE
THE POST TEST
Step
1.
Click on the appropriate link below. This
will take you to the post-test.
Step
2.
If you have participated in a Johns Hopkins
on-line course, login. Otherwise, please register.
Step
3.
Complete the post-test and course evaluation.
Step
4.
Print out your certificate.
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