LETTER TO THE EDITOR
Minimizing Antibiotic Misuse through Evidence-Based Management of Outpatient Acute Respiratory Infections Guillermo V. Sanchez, Katherine E. Fleming-Dutra, Lauri A. Hicks Get Smart: Know When Antibiotics Work Program, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
I
t was with considerable interest that we read the study by Schroeck et al. (1), which assessed the appropriateness of treatment for acute respiratory infections (ARIs) in the Veterans Affairs Western New York Healthcare System. These infections represent a large portion of injudicious antibiotic use among outpatients, and we applaud the authors for focusing on these conditions in the veteran population. However, we would like to clarify that clinical practice guidelines regarding the management of ARIs are published by professional societies such as the Infectious Diseases Society of America (IDSA) and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and not by the Centers for Disease Control and Prevention (CDC). The CDC’s Get Smart: Know When Antibiotics Work Program consolidates recommendations from the different guidelines into easy-to-use resources to help clinicians optimize outpatient antibiotic therapy (2). Although the authors cite the Get Smart Program as providing the criteria to diagnose and manage ARIs, the definitions of the clinical conditions presented do not accurately reflect current clinical practice guidelines or current Get Smart recommendations. For pharyngitis, the authors used a clinical prediction rule (Centor criteria) to determine if antibiotic treatment for pharyngitis was appropriate. However, using prediction rules to establish a group A streptococcal (GAS) pharyngitis diagnosis is not the approach recommended by the IDSA guidelines or the Get Smart Program (3). The Get Smart Program recommends that patients be screened by using Centor criteria (tender cervical lymphadenopathy, absence of cough, fever, or tonsillar exudates) to determine which patients should receive testing. Adult patients meeting two or more criteria should receive rapid antigen detection testing (RADT) to establish a diagnosis. According to IDSA guidelines, “clinical features alone do not discriminate between GAS and viral pharyngitis” and RADT testing or culture should be performed to establish a diagnosis of GAS pharyngitis (3). Since patients in this study were diagnosed by using clinical criteria without testing, the authors may have underestimated the level of inappropriate antibiotic use for pharyngitis. For sinusitis, the authors’ description of “severe symptoms, including high fever. . .and purulent nasal discharge or facial pain lasting for at least 3 to 4 consecutive days” is appropriate to establish the diagnosis of acute bacterial rhinosinusitis; however, IDSA and AAO-HNS recommendations also define a bacterial diagnosis as persistent symptoms such as nasal discharge or daytime cough without improvement for at least 10 days or worsening symptoms after initial improvement of a preceding viral upper respiratory tract infection. Because of a growing body of evidence demonstrating a lack of benefit from antibiotic therapy for the treatment of sinusitis (4), newer AAO-HNS guidelines recommend watchful
October 2015 Volume 59 Number 10
waiting for uncomplicated cases of bacterial rhinosinusitis for which reliable follow-up is available (5). Get Smart Program recommendations, clinical practice guidelines, and relevant citations for the diagnosis and management of ARIs are available at www.cdc.gov/getsmart/community. We agree with the authors’ conclusion that expansion of “stewardship programs. . . [in] the outpatient setting is necessary to combat. . .inappropriate antibiotic use” and look forward to working together to improve prescribing for common outpatient infections in the future. ACKNOWLEDGMENTS This material is the result of work supported by resources and facilities at the Centers for Disease Control and Prevention. The contents of this letter are not intended to represent the views of the Centers for Disease Control and Prevention or the United States government. We have no conflicts of interest to report.
REFERENCES 1. Schroeck JL, Ruh CA, Sellick JA, Ott MC, Mattappallil A, Mergenhagen KA. 2015. Factors associated with antibiotic misuse in outpatient treatment for upper respiratory tract infections. Antimicrob Agents Chemother 59: 3848 –3852. http://dx.doi.org/10.1128/AAC.00652-15. 2. Get Smart: Know When Antibiotics Work. 17 April 2015. Outpatient healthcare professionals: treatment recommendations for appropriate antibiotic prescribing. Centers for Disease Control and Prevention, Atlanta, GA. http://www.cdc.gov/getsmart/community/for-hcp/outpatient -hcp/index.html. Accessed 1 July 2015. 3. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C, Infectious Diseases Society of America. 2012. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 55:e86 –102. http://dx.doi.org/10.1093 /cid/cis629. 4. Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams JW, Jr, Mäkelä M. 2014. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev 2014:CD000243. 5. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, Orlandi RR, Palmer JN, Patel ZM, Peters A, Walsh SA, Corrigan MD. 2015. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 152(2 Suppl):S1–S39.
Citation Sanchez GV, Fleming-Dutra KE, Hicks LA. 2015. Minimizing antibiotic misuse through evidence-based management of outpatient acute respiratory infections. Antimicrob Agents Chemother 59:6673. doi:10.1128/AAC.01709-15. Address correspondence to Guillermo V. Sanchez, [email protected]. For the author reply, see doi:10.1128/AAC.01756-15. Copyright © 2015, American Society for Microbiology. All Rights Reserved. doi:10.1128/AAC.01709-15
Antimicrobial Agents and Chemotherapy
aac.asm.org
6673
Minimizing Antibiotic Misuse through Evidence-Based Management of Outpatient Acute Respiratory Infections Guillermo V. Sanchez, Katherine E. Fleming-Dutra, Lauri A. Hicks Get Smart: Know When Antibiotics Work Program, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
I
t was with considerable interest that we read the study by Schroeck et al. (1), which assessed the appropriateness of treatment for acute respiratory infections (ARIs) in the Veterans Affairs Western New York Healthcare System. These infections represent a large portion of injudicious antibiotic use among outpatients, and we applaud the authors for focusing on these conditions in the veteran population. However, we would like to clarify that clinical practice guidelines regarding the management of ARIs are published by professional societies such as the Infectious Diseases Society of America (IDSA) and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and not by the Centers for Disease Control and Prevention (CDC). The CDC’s Get Smart: Know When Antibiotics Work Program consolidates recommendations from the different guidelines into easy-to-use resources to help clinicians optimize outpatient antibiotic therapy (2). Although the authors cite the Get Smart Program as providing the criteria to diagnose and manage ARIs, the definitions of the clinical conditions presented do not accurately reflect current clinical practice guidelines or current Get Smart recommendations. For pharyngitis, the authors used a clinical prediction rule (Centor criteria) to determine if antibiotic treatment for pharyngitis was appropriate. However, using prediction rules to establish a group A streptococcal (GAS) pharyngitis diagnosis is not the approach recommended by the IDSA guidelines or the Get Smart Program (3). The Get Smart Program recommends that patients be screened by using Centor criteria (tender cervical lymphadenopathy, absence of cough, fever, or tonsillar exudates) to determine which patients should receive testing. Adult patients meeting two or more criteria should receive rapid antigen detection testing (RADT) to establish a diagnosis. According to IDSA guidelines, “clinical features alone do not discriminate between GAS and viral pharyngitis” and RADT testing or culture should be performed to establish a diagnosis of GAS pharyngitis (3). Since patients in this study were diagnosed by using clinical criteria without testing, the authors may have underestimated the level of inappropriate antibiotic use for pharyngitis. For sinusitis, the authors’ description of “severe symptoms, including high fever. . .and purulent nasal discharge or facial pain lasting for at least 3 to 4 consecutive days” is appropriate to establish the diagnosis of acute bacterial rhinosinusitis; however, IDSA and AAO-HNS recommendations also define a bacterial diagnosis as persistent symptoms such as nasal discharge or daytime cough without improvement for at least 10 days or worsening symptoms after initial improvement of a preceding viral upper respiratory tract infection. Because of a growing body of evidence demonstrating a lack of benefit from antibiotic therapy for the treatment of sinusitis (4), newer AAO-HNS guidelines recommend watchful
October 2015 Volume 59 Number 10
waiting for uncomplicated cases of bacterial rhinosinusitis for which reliable follow-up is available (5). Get Smart Program recommendations, clinical practice guidelines, and relevant citations for the diagnosis and management of ARIs are available at www.cdc.gov/getsmart/community. We agree with the authors’ conclusion that expansion of “stewardship programs. . . [in] the outpatient setting is necessary to combat. . .inappropriate antibiotic use” and look forward to working together to improve prescribing for common outpatient infections in the future. ACKNOWLEDGMENTS This material is the result of work supported by resources and facilities at the Centers for Disease Control and Prevention. The contents of this letter are not intended to represent the views of the Centers for Disease Control and Prevention or the United States government. We have no conflicts of interest to report.
REFERENCES 1. Schroeck JL, Ruh CA, Sellick JA, Ott MC, Mattappallil A, Mergenhagen KA. 2015. Factors associated with antibiotic misuse in outpatient treatment for upper respiratory tract infections. Antimicrob Agents Chemother 59: 3848 –3852. http://dx.doi.org/10.1128/AAC.00652-15. 2. Get Smart: Know When Antibiotics Work. 17 April 2015. Outpatient healthcare professionals: treatment recommendations for appropriate antibiotic prescribing. Centers for Disease Control and Prevention, Atlanta, GA. http://www.cdc.gov/getsmart/community/for-hcp/outpatient -hcp/index.html. Accessed 1 July 2015. 3. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C, Infectious Diseases Society of America. 2012. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 55:e86 –102. http://dx.doi.org/10.1093 /cid/cis629. 4. Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams JW, Jr, Mäkelä M. 2014. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev 2014:CD000243. 5. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, Orlandi RR, Palmer JN, Patel ZM, Peters A, Walsh SA, Corrigan MD. 2015. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 152(2 Suppl):S1–S39.
Citation Sanchez GV, Fleming-Dutra KE, Hicks LA. 2015. Minimizing antibiotic misuse through evidence-based management of outpatient acute respiratory infections. Antimicrob Agents Chemother 59:6673. doi:10.1128/AAC.01709-15. Address correspondence to Guillermo V. Sanchez, [email protected]. For the author reply, see doi:10.1128/AAC.01756-15. Copyright © 2015, American Society for Microbiology. All Rights Reserved. doi:10.1128/AAC.01709-15
Antimicrobial Agents and Chemotherapy
aac.asm.org
6673
