ITEMS IN AFP WITH MESH TERM:
Respiratory Tract Infections
ABSTRACT: Antibiotic resistance was once confined primarily to hospitals but is becoming increasingly prevalent in family practice settings, making daily therapeutic decisions more challenging. Recent reports of pediatric deaths and illnesses in communities in the United States have raised concerns about the implications and future of antibiotic resistance. Because 20 percent to 50 percent of antibiotic prescriptions in community settings are believed to be unnecessary, primary care physicians must adjust their prescribing behaviors to ensure that the crisis does not worsen. Clinicians should not accommodate patient demands for unnecessary antibiotics and should take steps to educate patients about the prudent use of these drugs. Prescriptions for targeted-spectrum antibiotics, when appropriate, can help preserve the normal susceptible flora. Antimicrobials intended for the treatment of bacterial infections should not be used to manage viral illnesses. Local resistance trends may be used to guide prescribing decisions.
ABSTRACT: Chemical dependency is a common, chronic disease that affects up to 25 percent of patients seen in primary care practices. The treatment goal for patients recovering from chemical dependency should be to avoid relapse. This requires physicians to have an open, nonjudgmental attitude and specific expertise about the implications of addiction for other health problems. First-line treatment for chemical dependency should be nonpharmacologic, but when medication is necessary, physicians should avoid drugs that have the potential for abuse or addiction. Medications that sedate or otherwise impair judgment also should be avoided in the recovering patient. Psychiatric illnesses should be aggressively treated, because untreated symptoms increase the risk of relapse into chemical dependency. Selective serotonin reuptake inhibitors may help to lower alcohol consumption in depressed patients, and desipramine may help to facilitate abstinence in persons addicted to cocaine. If insomnia extends beyond the acute or postacute withdrawal period, trazodone may be an effective treatment. If nonpharmacologic management of pain is not possible, nonaddictive medications should be used. However, if non-addictive medications fail, long-acting opiates used under strict supervision may be considered. Uncontrolled pain in itself is a relapse risk.
ABSTRACT: This article summarizes the principles of judicious antimicrobial therapy for three of the five conditions--cough, pharyngitis, the common cold--that account for most of the outpatient use of these drugs in the United States. The principles governing the other two conditions, otitis media and acute sinusitis, were presented in the previous issue. This article summarizes evidence against the use of antibiotic treatment for illness with cough or bronchitis in children, unless the cough is prolonged. Although empiric treatment may be started in patients with pharyngitis when streptococcal infection is suspected, the authors recommend withholding antibiotic treatment until antigen testing or culture is positive. There is never any indication for antibiotic treatment of the common cold; it is important to understand the natural history of colds, because symptoms such as mucopurulent rhinitis or cough, even when they persist for up to two weeks, do not necessarily indicate bacterial infection.
ABSTRACT: Compared with community-dwelling persons, residents in long-term care facilities have more functional disabilities and underlying medical illnesses and are at increased risk of acquiring infectious diseases. Pneumonia is the leading cause of morbidity and mortality in this group. Risk factors include unwitnessed aspiration, sedative medication, and comorbidity. Recognition may be delayed because, in this population, pneumonia often presents without fever, cough, or dyspnea. Accurate identification of the etiologic agent is hampered because most patients cannot produce a suitable sputum specimen. It is difficult to distinguish colonization from infection. Colonization by Staphylococcus aureus and gram-negative organisms can result from aspiration of oral or gastric contents, which could lead to pneumonia. Aspiration of gastric contents also can produce aspiration pneumonitis. This condition is not infectious initially and may resolve without antibiotics. Antibiotics for the treatment of pneumonia should cover Streptococcus pneumoniae, Haemophilus influenzae, gram-negative rods, and S. aureus. Acceptable choices include quinolones or an extended-spectrum beta-lactam plus a macrolide. Treatment should last 10 to 14 days. Pneumonia is associated with significant mortality for up to two years. Dementia is related independently to the death rate within the first week after pneumonia, regardless of treatment. Prevention strategies include vaccination against S. pneumoniae and influenza on admission to the care facility. This article focuses on recent recommendations for the recognition of respiratory symptoms and criteria for the designation of probable pneumonia, and provides a guide to hospitalization, antibiotic use, and prevention.
ABSTRACT: Acute rhinosinusitis is one of the most common conditions that physicians treat in ambulatory practice. Although often caused by viruses, it sometimes is caused by bacteria, a condition that is called acute bacterial rhinosinusitis. The signs and symptoms of acute bacterial rhinosinusitis and prolonged viral upper respiratory infection are similar, which makes accurate clinical diagnosis difficult. Because two thirds of patients with acute bacterial rhinosinusitis improve without antibiotic treatment and most patients with viral upper respiratory infection improve within seven d antibiotic therapy should be reserved for use in patients who have had symptoms for more than seven days and meet clinical criteria. Four signs and symptoms are the most helpful in predicting acute bacterial rhinosinusitis: purulent nasal discharge, maxillary tooth or facial pain (especially unilateral), unilateral maxillary sinus tenderness, and worsening symptoms after initial improvement. Sinus radiography and ultrasonography are not recommended in the diagnosis of uncomplicated acute bacterial rhinosinusitis, although computed tomography has a role in the care of patients with recurrent or chronic symptoms.
ABSTRACT: To help physicians with the appropriate use of antibiotics in children and adults with upper respiratory tract infection, a multidisciplinary team evaluated existing guidelines and summarized key practice points. Acute otitis media in children should be diagnosed only if there is abrupt onset, signs of middle ear effusion, and symptoms of inflammation. A period of observation without immediate use of antibiotics is an option for certain children. In patients with sinus infection, acute bacterial rhinosinusitis should be diagnosed and treated with antibiotics only if symptoms have not improved after 10 days or have worsened after five to seven days. In patients with sore throat, a diagnosis of group A beta-hemolytic streptococcus pharyngitis generally requires confirmation with rapid antigen testing, although other guidelines allow for empiric therapy if a validated clinical rule suggests a high likelihood of infection. Acute bronchitis in otherwise healthy adults should not be treated with antibiotics; delayed prescriptions may help ease patient fears and simultaneously reduce inappropriate use of antibiotics.
Procalcitonin-Guided Treatment of Respiratory Tract Infections - Point-of-Care Guides
Should We Recommend Nicotine Replacement Therapy? - Cochrane for Clinicians
Principles of Appropriate Antibiotic Use: Part I. Acute Respiratory Tract Infections - Practice Guidelines