Diagnosis and treatment of upper respiratory tract infections in the primary care setting

Background: Acute respiratory tract infections such as acute exacerbations of chronic bronchitis (AECB), acute otitis media (AOM), and acute bacterial rhinosinusitis (ABRS) account for similar to 75% of antibiotic prescriptio ns written and are among the leading reasons for physician office visits in the United States. Resistance of the predominant pathogens in respiratory tract infections (Streptococcus pneumoniae, Haemophilus influenzae, and Mor axella catarrhalis) to available antibiotics has led clinicians to reevalua te the diagnosis and management of these infections. Objective: The purpose of this review is to provide primary care practition ers with an accessible combined resource for the management of AECB, AOM, a nd ABRS. Methods: This review was based on discussions from a roundtable meeting (sp onsored by an educational grant from GlaxoSmithKline) that convened clinici ans versed in the management of upper and lower respiratory tract infection s. In addition, primary articles were identified by a MEDLINE search and th rough secondary sources. Results: To reduce the prevalence of resistance, judicious and appropriate use of antibiotics must be implemented in clinical practice. With accurate diagnosis of bacterial and nonbacterial conditions, and patient education o n antibiotic use and misuse, the excessive use of antibiotics and ensuing r esistance can be reduced. The incorporation of pharmacokinetic and pharmaco dynamic data with minimum inhibitory concentration values can provide a mor e comprehensive assessment of antibiotic activity in vivo. Stratification o f patients with AECB according to patient characteristics and frequency of exacerbation can be used to determine which patients will benefit from anti biotic treatment and to guide clinicians in their choice of antibiotic. The Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group has issu ed recommendations on the management of AOM based on prior antibiotic thera py, which is a risk factor for antimicrobial resistance. The Sinus and Alle rgy Health Partnership guidelines for the treatment of ABRS in adults and c hildren are based on the predicted efficacy of various antibiotics as well as patient age, severity of disease, likelihood of bacterial infection, lik elihood of spontaneous resolution, and in vitro susceptibility of the predo minant pathogens based on pharmacokinetic and pharmacodynamic breakpoints. Conclusions: Guidelines for the management of AECB, AOM, and ABRS emphasize the importance of differentiating between bacterial and nonbacterial infec tions, choosing an antibiotic based on the likelihood of infection with res istant pathogens, and providing coverage against the predominant pathogens. The judicious use of antibiotics also has been identified as an instrument al part of controlling unnecessary antibiotic use and subsequent resistance .