Inappropriate Use of Antibiotics During Upper Respiratory Infections

Upper respiratory infections (URI) have been a common indication for patients to seek medical treatment in the primary care setting. It is estimated that children age four and younger are diagnosed with have approximately 4.9 URIs per year, and the rate for children between the age of five and 19 is 2.8 per year.¹ On average, adults age 19-39 present are diagnosed with having 2.2 URI per year and adults age 40 and over having 1.6 per year.¹ In the United States, URI are associated with 50 % of school absenteeism in children and a total of 42 million missed days of work and school days annually.²

These staggering percentages create an economic burden of 40 billion dollars annually for URI.² In the United States, the annual costs associated with the inappropriate utilization of antibiotics for treatment URI in both children and adults is three billion dollars.³ With that being said, URI are considered to be the most treated acute problem in primary care.⁴

Inappropriate antibiotic prescribing is at an alarming rate of 40 to 50% for viral respiratory infections.¹ The misuse of antibiotics has led to an overgrowth of antimicrobial resistant organisms. A major contributing factor associated with antimicrobial resistance is the overutilization of antibiotics during viral infections.

Origins of Upper Respiratory Infections

Upper respiratory infections can be described as viral or bacterial infections that involve the nose, paranasal sinuses, pharynx, larynx, trachea and bronchi.¹ Approximately 90 to 98% of URIs are viral in origin. Treatment with an antibiotic will not be effective in alleviating the symptoms.⁵ Secondary infections, which are generally bacterial and account for approximately 2-10% of the URI seen in practice, may develop.⁵ The virus or bacteria enter the body directly or indirectly by aerosolized particles through the mucous membranes of the nose, mouth or eyes.^{1, 3}

Most viral URI can be linked to rhinoviruses which rarely causes serious complications.^{1, 3} Less common viral pathogens that are known to cause URI include respiratory syncytial virus, adenovirus, coronavirus, influenza, parainfluenza and metapneumovirus.^1,3 Bacterial URI have known etiologies agents that include S.pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Bordetella pertussis.^{1, 3} URI can be further classified into several types of infection to include: the common cold, rhinosinusitis, pharyngitis, bronchitis, otitis media, influenza and pneumonia.¹

Viral symptoms begin two to three days after inoculation and generally last six to nine days in children and three to fourteen days in adults.⁶ Viral URIs typically present with the presence of a cough, scratchy throat and nasal symptoms such as nasal congestion and discharge.⁵ Other symptoms can include fever, fatigue and headache, but such symptoms generally disappears after 24 to 48 hours.^1-9 Viral symptoms tend to resolve on their own within five to six days after initial onset. Bacterial infections are similar to those of viral infections however symptoms last beyond seven to ten days and are more severe in nature.^1-9

Patient Expectations

Research shows that many providers are prescribing antibiotics for viral infections solely due to patient expectations.^1,7 Providers may often feel pressured into giving antibiotics, especially with high practice volumes or with the uncertainty of the diagnosis.¹ Despite conventional methods of providing education during office visits regarding antibiotic usage during an URI, patients are still presenting to the office setting upon initial symptoms of an URI. In the past, patients may have received an antibiotic for similar symptoms and believe an antibiotic will make them feel better faster.¹ Viral URI can be treated -symptomatically with over-the-counter products and generally do not require an office visit. It is essential for providers to be able to differentiate between viral and bacterial URI in order to properly prescribe antibiotics.

According to the Infectious Diseases Society of America (IDSA), clinical guidelines for prescribing antibiotics should be aimed at prescribing for bacterial infections only. History and physical examination should identify persistent signs and symptoms lasting greater than ten days without improvement. ^5,7 Guidelines recommend that clinical presentation of three of the following can be consistent with a bacterial infection.^5,7 Severe symptoms can include high fever of greater than 39 degrees Celsius, purulent nasal discharge or facial pain lasting for at least three to four consecutive days, or worsening symptoms with new fever, headache or increased nasal discharge following a viral URI that lasted five to six days and initially started to improve.^5,7

Some patients with no co-morbidities or who are not immunocompromised with mild and persistent symptoms of a bacterial infection can be observed for an additional three days without initiation of antibiotics.⁵ However, these patients require close observation and it is essential that if symptoms do not resolve within three days that antibiotic treatment is initiated.⁵ Bacterial URI should be treated in order to prevent complications such as lower respiratory infection or respiratory failure. ⁵

Proper Treatment

Treatment of both viral and bacterial upper respiratory infections should include preventive measures. Engaging in good hand hygiene practices can help decrease causative agents associated with URIs.^1-9 It is important to encourage those who are sick to cover their mouth and nose when coughing and sneezing to help reduce the transmission of URIs.⁶ Maintaining yearly influenza and pneumococcal vaccinations, when appropriate, can also help decrease the risk of developing an URI. Viral URI can be managed with self-treatment therapies, including rest, fluids and relief of symptoms by using decongestants, nasal washes and pain control with acetaminophen or ibuprofen.^1-9

Providers can supply patients with symptom relief, reassurance and education regarding when to return if their symptoms are not improving.⁷ They can also write commitment letters to explain that providers in the practice will only be prescribing antibiotics if deemed necessary.⁷ Education can be implemented within the practice by utilizing low-cost interventions such as commitment letters posted in each exam room and viral versus bacterial infection educational posters to help increase patient awareness regarding antibiotic usage during URI.⁷ Another assessment tool for providers to utilize is the IDSA Clinical Practice Guidelines for Acute Bacterial Rhinosinusitis in children and adults.⁵ These guidelines address treatment and management of both viral and bacterial sinusitis.⁵ Providers can also encourage the use of over-the-counter products to help relieve symptoms.

Dangers of Antibiotic Resistance

The overutilization of antibiotics for viral infections has created a rise in antibiotic resistant organisms. In fact, treatment for a URI is the 5^th leading indication for antimicrobial prescriptions in outpatient practices.⁵ With that being said, 41% of the annual 100 million antibiotic prescriptions are being prescribed inappropriately for URI, thus leading to the increase in antimicrobial resistance in primary care.⁸

The inappropriate diagnoses and prescribing of antibiotics for an URI has led to an increase in antimicrobial resistance among respiratory pathogens like S. pneumoniae.^1-9 Resistant respiratory pathogens can lead to serious complications for patients, especially those with underlying respiratory diseases, by causing a self-perpetuating cycle in which broad-spectrum antibiotics are encouraged and in turn drive, selection pressure in promoting more resistance.⁵ One single course of an antibiotic has the potential to increase the risk of antimicrobial resistance for at least one year.⁹

Furthermore, the overutilization of antibiotics has resulted in antimicrobial resistance resulting in becoming a serious public health threat.^1,4 Annually in the United States, there are approximately two million antibiotic-resistant illnesses associated with 23,000 deaths, leading to 30 billion dollars in costs.³ Therefore, decreasing the inappropriate use of antibiotics during an URI will help aide in antibiotic resistance.

“Antimicrobial resistance poses a catastrophic threat. If we don’t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can’t be treated by antibiotics.”¹⁰ With that being said, upper respiratory infections are a common indication for patients to seek medical treatment. Therefore, it is essential for providers to properly identify and treat URI effectively in order to decrease antimicrobial resistance.

References

1. Hart AM, Patti A, Noggle B, et al. Acute respiratory infections and antimicrobial resistance. American Journal of Nursing. 2008;108(6):56-65.
2. Larson E, Ferng Y, Wong, J, et al. Knowledge and misconceptions regarding upper respiratory infections and influenza among urban Hispanic households:need for targeted messaging. 2009;11: 71-82. doi:10.1007/s10903-008-9154-2
3. Harris AM, Hicks LA, Qaseem A, et al. Appropriate antibiotic use for acute respiratory tract infections in adults: advice for high-value care from the American college of physicians and the Centers for Disease Control and Prevention. Annals of Internal Medicine. 2016;164(6):425-434. doi:10.7326/M15-1840
4. Kotwani A, Holloway K. Antibiotics prescribing practice for acute, uncomplicated respiratory tract infections in primary care settings in New Delhi, India. Tropical Medicine and International Health. 2014;19(2):761-768. doi:10.1111/tmi.12327
5. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guidelines for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases Society of America. 2012:1-41. doi:10.1093/cid/cir1043.
6. Meneghetti A, Mosenifar Z. Upper respiratory tract infection clinical presentation. Medscape.2015. http://emedicine.medscape.com/article/302460-clinical Accessed February 5, 2016.
7. Soltwisch M, Beckham N. Reducing the inappropriate prescribing of antibiotics for rhinosinusitis. Consultant.2016:127-132.
8. Biscaldi L. CDC, ACP issue guidelines for antibiotic use for acute respiratory tract infections, The Clinical Advisor, Newsline. 2016:14.
9. Holmes S, Scullion J. Prescribing for upper respiratory tract infection. Practice Nursing. 2014;25(1):18-22.
10. United Solutions. TARGET antibiotic toolkit. Royal College of General Practitioners. 2014.http://www.rcgp.org.uk/clinical-and-research/toolkits/target-antibiotics-toolkit.aspx Accessed March 30, 2016.