Infectious Disease Guidelines :principles Of Judicious Use Of Antimicrobial Agents.

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Cough Illness/Bronchitis

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Evidence that children with cough for 10 days should not be treated with antimicrobial agents is presented. Older children with prolonged cough or those with underlying lung disease may benefit from antimicrobial treatment directed specifically at B pertussis, M pneumoniae, C pneumoniae, P aeruginosa, or other specific infections. None of the routinely prescribed cephalosporin or amino penicillin antimicrobials would be effective for these organisms. Noninfectious diagnosis should be sought in children with markedly prolonged cough.

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Acute Bronchitis: (Uncomplicated)

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1. The evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out serious illness, particularly pneumonia. 2. Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. If pertussis infection is suspected (an unusual circumstance), a diagnostic test should be performed and antimicrobial therapy initiated.

3. Patient satisfaction with care for acute bronchitis depends most on physician–patient communication rather than on antibiotic treatment.

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Common Cold

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Most children will suffer between 3 and 8 colds per year, and over half of patients seen for the common cold are given an antimicrobial prescription. Unnecessary antimicrobial therapy can be avoided by recognizing the signs and symptoms that are part of the usual course of these diseases. antimicrobial therapy for patients with viral rhinosinusitis is not an effective way to prevent bacterial complications. Mucopurulent rhinitis (thick, opaque, or discolored nasal discharge) frequently accompanies the common cold and is part of the natural course of viral rhinosinusitis. It is not an indication for antimicrobial treatment unless it persists without improvement for >10 to 14 days.

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Otitis Media

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Otitis media is the leading indication for outpatient antimicrobial use in the United States. Overdiagnosis of and unnecessary prescribing for this condition has contributed to the spread of antimicrobial resistance. A critical step in reducing unnecessary prescribing is to identify the subset of patients who are unlikely to benefit from antibiotics. Conscientiously distinguishing acute otitis media (AOM) from otitis media with effusion (OME), and deferring antibiotics for OME will accomplish this goal, and will avoid up to 8 million unnecessary courses of antibiotics annually.

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Pharyngitis

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Accurate diagnosis of group A streptococcal pharyngitis and appropriate antimicrobial therapy are important, particularly to prevent nonsuppurative sequelae such as rheumatic fever. Most episodes of sore throat, however, are caused by viral agents. Clinical findings cannot reliably differentiate streptococcal from viral pharyngitis and most physicians tend to overestimate the probability of a streptococcal infection based on history and physical examination alone. Therefore, diagnosis should be based on results of a throat culture or an antigen-detection test with throat culture backup. Presumptively starting therapy pending results of a culture is discouraged because treatment often continues despite a negative test result. Other bacterial causes of pharyngitis are uncommon and often can be diagnosed based on nonpharyngeal findings. Penicillin remains the drug of choice for streptococcal pharyngitis because of its effectiveness, relatively narrow spectrum, and low cost.

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Acute Respiratory Tract Infections in Adults

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colds, nonspecific upper respiratory tract infections, and acute bronchitis (for which routine antibiotic treatment is not recommended)—a large proportion of the antibiotics prescribed are unlikely to provide clinical benefit to patients. Because decreasing community use of antibiotics is an important strategy for combating the increase in community-acquired antibiotic-resistant infections

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Nonspecific Upper Respiratory Tract Infections in Adults

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1. The diagnosis of nonspecific upper respiratory tract infection or acute rhinopharyngitis should be used to denote an acute infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent.

2. Antibiotic treatment of adults with nonspecific upper respiratory tract infection does not enhance illness resolution and is not recommended.
3. Purulent secretions from the nares or throat (commonly observed in patients with uncomplicated upper respiratory tract infection) predict neither bacterial infection nor benefit from antibiotic treatment.

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Pediatric Upper Respiratory Tract Infections

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Antimicrobial drug use rates are highest for children; therefore, the pediatric age group represents the focus for the present guidelines. The evidence-based principles presented here are focused on situations in which antimicrobial therapy could be curtailed without compromising patient care. They are not formulated as comprehensive management strategies. For most upper respiratory infections that require antimicrobial treatment, there are several appropriate oral agents from which to choose. Although the general principles of selecting narrow-spectrum agents with the fewest side effects and lowest cost are important, the principles that follow include few specific antibiotic selection recommendations

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Acute Rhinosinusitis in Adults

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1. Most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections.

2. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especially when unilateral) and purulent nasal secretions. Patients with rhinosinusitis symptoms that last less than 7 days are unlikely to have bacterial infection, although rarely some patients with acute bacterial rhinosinusitis present with dramatic symptoms of severe unilateral maxillary pain, swelling, and fever.

3. Sinus radiography is not recommended for diagnosis in routine cases.

4. Acute rhinosinusitis resolves without antibiotic treatment in most cases. Symptomatic treatment and reassurance is the preferred initial management strategy for patients with mild symptoms. Antibiotic therapy should be reserved for patients with moderately severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis and for those with severe rhinosinusitis symptoms—especially those with unilateral facial pain—regardless of duration of illness. For initial treatment, the most narrow-spectrum agent active against the likely pathogens, Streptococcus pneumoniae and Haemophilus influenzae, should be used.

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Acute Sinusitis

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Establishing an accurate diagnosis of bacterial sinusitis is challenging but critical, because viral rhinosinusitis is at least 20 to 200 times more common than bacterial infection of the sinuses. Strict criteria for clinical diagnosis that require either prolonged and persistent symptoms or an acute severe presentation

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Staphylococci

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the most common causes of community- and hospital-acquired infection. In many U.S. hospitals, strains of staphylococci (i.e., Staphylococcus aureus or coagulase-negative staphylococci) are resistant to all available antimicrobials except vancomycin.

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Preventing the Spread of Staphylococci

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Medical and nursing staff should :

isolate the patient in a private room and use contact precautions (gown, mask, glove, and antibacterial soap for handwashing) as recommended for multidrug-resistant organisms (6);

minimize the number of persons with access to colonized/infected patients; and

dedicate specific health-care workers to provide one-on-one care for the colonized/infected patient or the cohort of colonized/infected patients.

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Recommendations for Preventing the Spread of Vancomycin Resistance Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC)

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Each hospital -- through collaboration of its quality-improvement and infection-control programs; pharmacy and therapeutics committee; microbiology laboratory; clinical departments; and nursing, administrative, and housekeeping services -- should develop a comprehensive, institution-specific, strategic plan to detect, prevent, and control infection and colonization with VRE. The following elements should be addressed in the plan.

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Vancomycin resistance in enterococci (VRE)

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has coincided with the increasing incidence of high-level enterococcal resistance to penicillin and aminoglycosides, thus presenting a challenge for physicians who treat patients who have infections caused by these microorganisms

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epidemiology of VRE

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not been clarified; however, certain patient populations are at increased risk for VRE infection or colonization. These populations include critically ill patients or those with severe underlying disease or immunosuppression (e.g., patients in ICUs or in oncology or transplant wards); persons who have had an intraabdominal or cardio-thoracic surgical procedure or an indwelling urinary or central venous catheter; and persons who have had a prolonged hospital stay or received multiantimicrobial and/or vancomycin therapy (2-8). Because enterococci are part of the normal flora of the gastrointestinal and female genital tracts, most infections with these microorganisms have been attributed to the patient's endogenous flora (15). However, recent studies have indicated that VRE and other enterococci can be transmitted directly by patient-to-patient contact or indirectly by transient carriage on the hands of personnel (16) or by contaminated environmental surfaces and patient-care equipment