Antibiotics for Acute URTIs

Sniffle! Cough! Sneeze! Come fall and winter, these harmonious sounds amplify in clinic waiting rooms, schools, and work facilities. For many, upper respiratory tract infections (URTIs) register as a small blip on the radar, serving as a nuisance that is counted down on a 7- to 14-day recovery clock. To others, it can be a scary time of balancing a chronic illness, such as a teetering asthmatic. Regardless of how, URTIs directly or indirectly touch all lives with an average incidence of 5 to 7 episodes in younger children and 2 to 3 episodes in adults annually. As the seasonal revolving door begins turning, so do health care providers in their challenges to serve as stewards of appropriate antibiotic usage.

Antibiotic Stewardship

More than 200 viruses have been identified as attributing factors to URTIs.¹Rarely do infections of the upper respiratory tract require or escalate to the point of requiring an antibiotic. Yet, the tug-o-war between patient requests and provider guideline adherence is an everyday reality in health care.

"Antibiotic stewardship" is not a catchy term or a health care fad. It's a necessity for long-term survival to preserve antimicrobials and prevent downstream resistance. With utilization of an antibiotic, the opportunity for the evolution of a “super bug” emerging with superior alterations to combat future efficacy develops. This not only occurs at an individual level but also impacts the resistance of potential infections to the entire community. Appropriate antibiotic prescription is a quality-of-care issue. Antibiotic stewardship optimizes the use of antibiotics through strategic selection of who, what, when, where, and how the medication is received.

Approximately half of prescribed antibiotics are inappropriate.¹Ranking high atop the list of antibiotic misuse are patients seeking care for viral acute URTIs.²Most clinicians spout off guidelines with ease but fail to follow those guidelines. Why? The tug-o-war is real. Patient pressure and quality ratings derived from customer satisfaction name a few arguments for the flawed execution. Clinicians are in the business to “do no harm.” There is no doubt that dethroning a patient’s beloved Zpak could sway pa- tient-clinician trust. When perception is reality, counseling around antibiotic fallacy may be seen as a threat to the patient that his or her need will not be satisfied. However, the real harm is prescribing an unneeded antibiotic.

The ability to read emotional queues, determine root of beliefs, and empathetically translate an understanding—all while providing a “why”—takes finesse and practice. Clinicians trained in communication strategies have shown nearly a 15% downward shift in antibiotic prescribing.³In determining that an antibiotic is not needed, most patients are satisfied with recommendations or a prescription for alternate symptom relief alone. Others may require a deeper explanation reviewing virus versus bacteria in a bite-sized, digestible format that is palatable and can be consumed in 3 minutes or less. Delayed antibiotic prescriptions—a practice in which a prescription is provided to be filled if symptoms persist or worsen after an outlined period of time—has shown to decrease antibiotic use while still providing a safety net to the patient. Technique should be tailored on a patient-by-patient basis.

Appropriate Antibiotic Use

Delayed use and prevention of misuse is etched in the brains of clinicians and rising in awareness in the patient population. On the flip side to the antibiotic stewardship double-edged sword, it may be just as important to take antibiotics if the infection is caused by bacteria. The following includes a brief review of URTIs and indications for antibiotics.

Acute Bacterial Rhinosinusitis

Persistent nasal drainage lasting more than 10 days, worsening course after initial improvement, or severe onset with fever of 102 degrees or higher with nasal discharge for 3 or more days are indications that bacteria may be present in a young child with acute rhinosinusitis. Older children and adults may also experience localized pain and tenderness specific to the affected sinus. Streptococcus pneumonia followed by Haemophilius influenza are the leading pathogens in incidences of acute bacterial rhinosinusitis.⁴Where sole symptomatic treatment is not appropriate, amoxicillin-clavulanate is the recommended initial therapy for patients without risk factors for antibiotic resistance. In patients who are allergic to penicillin, doxycycline or clindamycin are alternative options. For patients with risk factors for antibiotic resistance, high-dose amoxicillin-clavulanate should be used.

Acute Otitis Media

While watchful waiting is the preferred treatment for acute otitis media (AOM) in children 2 years or older, antibiotics are indicated when: otalgia is present for longer than 48 hours, temperature exceeds 102.2 within the past 48 hours, bilateral tympanic membranes are affected, otorrhea is present, access for follow-up may be limited, or immunocompetency is of concern.⁵AOM in adults may be treated with antibiotics rather than watchful waiting. The preferred drug for treatment is amoxicillin or a macrolide in instances of patients allergic to penicillin. Cephalosporins may be used as an alternate for chil- dren allergic to penicillin, depending on reaction type.⁶

Epiglottitis

Epiglottitis is a potentially life-threatening illness with sudden onset. Symptoms include sore throat, drooling, muffled voice, dyspnea, fever, and fatigue. Haemophilus influenza type B (Hib) is the most common pathogen attributed to epiglottitis in children. In adults with epiglottitis, causes vary and often no identified pathogen is detectable. When a pathogen is detectable, Hib remains the most common offender in adults though identified in lower incidence.⁷Antibiotics covering suspect organisms should be initiated immediately and may be adjusted as indicated following culture results. Airway preservation is key in the treatment of epiglottitis through glucocorticoids, oxygen, and artificial airway dictated by severity.⁶

Strep Throat

Patients with Group A streptococcal (GAS) pharyngitis commonly present with exudative tonsils, temperature of 100.9 or higher, and enlarged (>1cm) tender anterior cervical nodes in the absence of coryza. Throat culture should be used to confirm a negative rapid strep test in children, as well as adults carrying high suspicion of GAS despite negative rapid result.⁸A 10-day regimen of penicillin V remains the preferred agent for treatment of GAS, though amoxicillin is often used more widely because it is more favorable to patient taste.⁹

Pertussis

Whooping cough is a highly contagious URTI that is characterized by inspiratory whoop in 30% of cases, violent coughing bursts, or post-tussive emesis. Bordetella pertussis is the offending pathogen in whooping cough. Although most individuals will improve over a month and a half, early intervention with antibiotics can help to decrease the duration, severity, and transmission to others. The CDC recommends using azithromycin or clarithromycin as preferred macrolides for treatment. Trimethoprim-sulfamethoxazole serves as the alternate option in patients unable to tolerate the macrolide of choice.¹⁰

Prevention of URTIs

Last, but undoubtedly the most important aspect in the treatment of URTIs, is primary prevention. Regular washing of hands, covering one’s mouth when coughing or sneezing, and keeping hands away from the eyes, nose, and mouth are simple actions that prevent the spread of URTIs from person to person. Consistent disinfection, particularly in high risk areas or places with increased foot traffic, is also valuable to keeping a cough-free community. Routine moderate exercise and engagement in stress-relieving activities contribute to boosting immunity.

The annual flu vaccine is the best way to prevent the spread of influenza throughout the community and should be strongly considered in individuals without contraindications. Flu-related deaths continue to strike each year. Although incidence and peak position vary each year, one thing is certain—the flu will always rear its ugly head. Assist in abolishing myths and protecting against this URTI through education and routine seasonal offering of the influenza immunization.

Conclusion

Fatigue, cough, congestion, along with any other variation of the URTI symptom continuum lead to decreased productivity and loss of days at school and work—sparing no age or schedule. Regardless of how, URTIs directly or indirectly touch all lives. Education and communication are just as important as the treatment and medication recommendations. Health care providers are called to meet the challenges that antibiotic stewardship poses in a balancing act that supports trust in the patient—provider relationship, expectation, and appropriate use to promote the highest quality of care for patients and the community.

Dr. Cathleen McKnight is a family nurse practitioner and currently serves as the Director of Patient Centered Strategies for The Little Clinic, a wholly owned subsidiary of The Kroger Co. In her role, McKnight is responsible for affiliation oversight, scope of service expansion, clinician education, and political advocacy. McKnight holds her doctorate of nursing practice from the University of Alabama and a master of science degree from The Ohio State University. She is board certified with the American Academy of Nurse Practitioners and a member of Sigma Theta Tau International Honors Society. McKnight currently serves as adjunct faculty for doctoral nursing students, is on the Editorial Board for Contemporary Clinic® and operates as a Key Person for the Ohio Association of Advanced Practice Nurses’ political initiatives. McKnight’s work is aimed at delivering The Little Clinic mission to offer America’s most convenient and accessible delivery of affordable health and wellness care for the whole family.

References:

1. Cals JW, de Bock L, Beckers PJ, et al. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory treat infection: 3.5-year follow-up of cluster randomized trial. Ann. Fam Med. 2013; 11(2):157-164.

2. Cooper RJ, Hoffman JR, Bartlett JG, Besser RE, Gonzales R, Hickner JM, & Sande MA. (2001). Principles of appropriate antibiotic use for acute pharyngitis in adults: background. American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine, Centers for Disease Control.Ann Intern Med. 2001;134(6):509.

3. Fashner J, Ericson K, & Werner S. (2012).Treatment of the common cold in children and adults.Am Fam Physician. 2012;86(2):153-9.

4. Gerber MA & Shulman ST. (2004). Rapid diagnosis of pharyngitis caused by group A streptococci.Clin Microbiol Rev. 2004;17(3):571.

5. Hoberman A, Ruohola A, Shaikh N, Tähtinen PA, & Paradise JL. (2013). Acute otitis media in children younger than 2 years.JAMA Pediatr. 2013 Dec;167(12):1171-2.

6. Shah RK, Roberson DW, & Jones DT. (2004). Epiglottitis in the Hemophilus influenzae type B vaccine era: changing trends.Laryngoscope. 2004;114(3):557.

7. Shapiro DJ, Hicks LA, Pavia AT, & Hersh AL. (2014). Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09.J Antimicrob Chemother.2014;69(1):234-40.

8. Sobol SE & Zapata S. (2008). Epiglottitis and croup.Otolaryngol ClinNorth Am. 2008;41(3):551.

9. Tiwari T, Murphy TV, & Moran J. (2005). National Immunization Program, CDC. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC Guidelines.MMWR Recomm Rep. 2005;54(RR-14):1.

10. Wald, E.R. (2011). Staphylococcus aureus: is it a pathogen of acute bacterial sinusitis in children and adults?Clin Infect Dis.2012 Mar;54(6):826-31. Epub 2011 Dec 23.