Practice Guidelines - August 1, 2001 - American Family Physician

Practice Guidelines

Principles of Appropriate Antibiotic Use: Part II. Nonspecific Upper Respiratory Tract Infections
Genevieve Ressel

Widespread use of antibiotics in agriculture, increased antibiotic use in children and excessive use of antibiotics in adults have caused an increase in antibiotic-resistant organisms in the past decade. To address this issue, the Centers for Disease Control and Prevention (CDC) assembled a panel of national health experts, including physicians with expertise in internal, family, emergency and infectious diseases medicine, to develop evidence-based guidelines for evaluating and treating adults with acute respiratory illness. The goal of the guidelines put together by the CDC and other members of the panel is to provide physicians with practical strategies for limiting antibiotic use to patients who are most likely to benefit. The complete treatment guidelines were published in the March 20, 2001 issue of Annals of Internal Medicine, and they can be viewed online at http://www.annals.org/issues/v134n6/full/200103200-00013.html.

Antibiotics are frequently prescribed for uncomplicated respiratory tract infections. These infections are the second leading condition for which antibiotics are prescribed each year, and they account for 10 percent of all prescriptions annually in ambulatory practice. Physicians have reported that unrealistic patient expectations, patient pressure to prescribe antibiotics and insufficient time to educate patients about the ineffectiveness of antibiotics are some of the reasons that so many prescriptions are written.

Clinical presentation also affects the decision to prescribe an antibiotic. Physicians identify and treat a subset of upper respiratory tract infections primarily characterized by the presence of purulent manifestations. Purulent or green nasal discharge, production of green phlegm, presence of tonsillar exudate and current tobacco use are independent predictors of antibiotic treatment. The more of these factors that are present, the more likely the physician is to prescribe an antibiotic.

The urgency of limiting antibiotic use in ambulatory practice has been fueled by the epidemic increase in antibiotic-resistant Streptococcus pneumoniae, which causes community-acquired bacterial pneumonia, bacterial meningitis, bacterial sinusitis and otitis media. Previous antibiotic use is the most important factor in carriage of and infection with antibiotic-resistant S. pneumoniae. Beyond reducing costs for patients and payers and the risk of side effects, reducing antibiotic use in the community will decrease the number of common antibiotic-resistant pathogens.

Recommendations

These recommendations apply only to immunocompetent adults with no important comorbid conditions, such as pulmonary or cardiac disease. Along with these guidelines, patient education is fundamental to decreasing unnecessary prescriptions.

In previously healthy adults, the diagnosis of nonspecific upper respiratory tract infection 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. Most cases of uncomplicated upper respiratory tract infection in adults resolve spontaneously. Symptoms typically last one to two weeks, and most patients feel better within the first week. These infections are predominantly viral in origin, and complications, such as bacterial rhinosinusitis or bacterial pneumonia, are rare.

Antibiotic treatment of adults with nonspecific upper respiratory tract infection is not recommended because it does not enhance illness resolution or alter the rates of uncommon complications.

Purulent nasal discharge and sputum do not predict bacterial infection and patients with these symptoms do not benefit from antibiotic treatment. Antibiotic therapy does not decrease the duration of symptoms or lost work time, or prevent complications.

This is the second of a five-part series summarizing the principles of appropriate antibiotic use gathered by the panel. The first part, on the appropriate use of antibiotics in acute respiratory infection, appeared in the July 15, 2001, issue of American Family Physician. The third article, on recommendations for antibiotic use in acute sinusitis, will appear in the next issue. Collaborating with the Centers for Disease Control and Prevention were the American College of PhysiciansAmerican Society of Internal Medicine, the American Academy of Family Physicians and the Infectious Diseases Society of America.

American Heart Association Scientific Statement on the Primary Prevention of Ischemic Stroke
Joanne Chatfield

The Stroke Council of the American Heart Association (AHA) has issued a scientific statement on the primary prevention of ischemic stroke. The statement is based on the findings of an ad hoc writing group formed by the AHA council to review pertinent literature, published guidelines and expert opinions regarding risk factors for ischemic stroke. The scientific statement includes an overview of established and potential risk factors and recommendations.

The AHA scientific statement appears in the January 2/9, 2001, issue of Circulation and can be accessed at the AHA Web site: http://www.circ.ahajournals.org/cgi/content/ full/103/163.

According to the AHA council, each recommendation is based on five different levels of evidence:

Level I: data from randomized trials with low false-positive and false-negative errors (grade A strength of evidence).

Level II: data from randomized trials with high false-positive or false-negative errors (grade B strength of evidence).

Level III: data from nonrandomized concurrent cohort studies (grade C strength of evidence).

Level IV: data from nonrandomized cohort studies using historical controls (grade C strength of evidence).

Level V: data from anecdotal case series (grade C strength of evidence).

Further classification within the AHA scientific statement includes the potential for modification (nonmodifiable, modifiable or potentially modifiable) of the identified risk factor and the strength of evidence (well documented, less well documented).

Nonmodifiable risk factors include age, sex, race/ethnicity and family history. Well-documented modifiable risk factors (all level I, grade A) include hypertension, smoking, diabetes/hyperinsulinemia/insulin resistance, asymptomatic carotid stenosis, atrial fibrillation, other cardiac disease (e.g., valvular heart disease, intracardiac congenital defects), sickle cell disease and hyperlipidemia.

From this category, hypertension, considered a major risk factor for stroke, remains underdiagnosed and inadequately treated. The relationship between stroke and systolic and diastolic blood pressures is "direct, continuous and apparently independent." More than 30 years of evidence reveals that adequately controlled hypertension is a factor in preventing stroke, as are beta-blocker and high-dose diuretic therapy. Particularly in elderly persons, isolated systolic hypertension is considered an important risk factor for stroke (systolic blood pressure of more than 160 mm Hg and diastolic blood pressure of less than 90 mm Hg). One trial involving 4,695 elderly patients with isolated systolic hypertension was terminated when a stroke reduction rate of 42 percent was reached in the patients who were actively treated compared with those taking placebo. The AHA recommends that adult patients undergo routine screening for hypertension at least every two years.

Risk factors in the less well-documented, potentially modifiable category include obesity, physical inactivity, poor diet/nutrition, alcohol abuse, hyperhomocysteinemia, drug abuse, hypercoagulability, hormone replacement therapy, oral contraceptive use and inflammatory processes.

The role of obesity in stroke is based on its predisposition to cardiovascular disease and its association with increased blood pressure, blood sugar and blood lipid levels. Although evidence from prospective randomized studies does not support a decreased risk of stroke directly related to weight loss, data from large level IV studies suggest that abdominal obesity, rather than body mass index (BMI) or general obesity, is more closely related to the risk of stroke in men. In women, obesity is associated with an increased risk of ischemic stroke with increasing BMI. The AHA endorses this data as strong enough to recommend that abdominal obesity in men and obesity and weight gain in women should be considered independent risk factors for stroke.

AHA Recommendations for the Management of Stroke Risk Factors

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

The management strategies for the above risk factors are outlined in the accompanying table and are based on published guidelines and/or consensus statements. Not included in the table are risk factors for which specific guidelines have not been previously adopted.

The AHA council notes that many gaps exist in the curent knowledge about risk factors for stroke. In addition, the effect of treatment of the less well-documented, potentially modifiable factors is uncertain, while further research is necessary to understand the differences between gender-specific risk factors.

Copyright © 2001 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

August 1, 2001 Contents | AFP Home Page | AAFP Home | Search