Avoid over-prescription of antibiotics for upper respiratory tract infections

NEW YORK — There are various socioeconomic factors such as competition from outside prescribers and family demands that may affect a physician’s decision to prescribe antibiotics for upper respiratory tract infections.

Stan L. Block, MD, professor of clinical pediatrics at the University of Kentucky College of Medicine in Lexington, and at the University of Louisville Medical School in Louisville, presented an overview of key issues pertaining to prescribing antibiotics for upper respiratory tract infections (URIs) at the 23rd Annual Infectious Diseases in Children Symposium held here.

Block, who is also an Infectious Diseases in Children Editorial Board member, cited data demonstrating the widespread health and economic effect of URIs and the potential to over-prescribe antibiotics.

According to background information cited by Block, URIs are the leading cause of acute morbidity and work/school absenteeism in the United States. Acute otitis media has an estimated annual cost of $6.8 billion, with 15.1 million visits occurring in children aged younger than 15 years. Acute bacterial rhinosinusitis comprises 9% of pediatric prescriptions and 21% of adult antibiotic prescriptions, for an annual cost of about $3.5 billion. Children aged younger than 15 years accounted for 6.1 million visits from pharyngitis.

In a study cited by Block, among 300 parents from suburban private practice and 100 parents from inner city practice, 18% gave antibiotics before the office visit. Fourteen percent reported that they were given no antibiotics during the office visit when they should have received antibiotics, and 9% said they thought that antibiotics were over-prescribed during the office visit.

Prescribe antibiotics thoughtfully

Block said there are appropriate methods for properly diagnosing pharyngitis, AOM and rhinorrhea as they relate to prescribing antibiotics.

For pharyngitis, the diagnosis should be based mostly upon a positive antigen detection test or a flora culture, according to Block. For AOM, diagnosis of a bacterial infection is based on the physical examination only.

“If the practitioner chooses a watchful waiting approach for AOM, make certain the child is over age 2, has almost no symptoms and excellent follow-up, and the parents are totally agreeable to this approach,” Block told Infectious Diseases in Children during an interview.

He said appropriate diagnostic criteria for AOM and highlighting the significance of considering “what you see, not what you hear (history)” is important. Visual criteria for diagnosing AOM included otorrhea, tympanic membrane position and tympanic membrane opacification plus certain discoloration, such as distinct or marked erythema or green, yellow, creamy white or cloudy coloration.

For rhinorrhea, practitioners should consider treatment with antibiotics only for those who have had prolonged, persistent symptomatic rhinorrhea with cough and malaise and who have generally been feeling poorly, Block said.

“The average rhinorrhea stops within 7 or 8 days. If it’s persisting with significant symptoms beyond that time, then diagnosis of sinusitis can be entertained,” he said.

“Additionally, for those who come in too early for the diagnosis of sinusitis, I recommend that practitioners ‘bargain with the early birds’ and withhold antibiotics and have them call back in 8 or 9 days after the rhinorrhea has begun,” Block said. “As long as the symptoms are still persistent and causing the child significant problems, then diagnosis of sinusitis by a phone call can be entertained at a later time because the diagnosis of sinusitis is based strictly upon clinical history and minimally upon the physical examination.”

Sinusitis is based exclusively on clinical history because the findings are so nonspecific; there are minimal clinical, physical findings with sinusitis that are reliable, according to Block.

Landscape still changing

The landscape of antibiotics and URIs continues to evolve. This includes a pathogen shift in AOM and the new effect of 13-valent pneumococcal conjugate vaccine (Prevnar 13, Wyeth) on AOM/sinusitis pathogens; managed care/CDC concerns; and adherence to and efficacy of antibiotics.

Additionally, a resistance problem with antibiotics remains because there are no rapid, sensitive/specific bacteriologic diagnostic tests for pathogen of AOM/sinusitis; antibiotic therapy is empiric; antibiotics are often unnecessary or too broadly used; over-use of antibiotics may accelerate resistant strains; there is parental pressure for antibiotics prescribing; and there are no oral antibiotics in the pipeline.

In terms of what can be done about the current mentality toward antibiotics, Block said it is unsafe to prescribe antibiotics just to “keep the family satisfied.”

He said influenza vaccinations, distributing specific handouts about the virus and requiring an office visit for antibiotic prescriptions are important. A more unified front for pediatricians is imperative, as well.

“For every antibiotic prescription, pretend your former chief of service is reviewing your exam and your plan,” Block said during his presentation. “Then ask if it’s justifiable to prescribe or not.”

For more information:

• Block SL. The ABCs of antibiotics for URIs: When antibiotics should and should not be considered. Presented at: the 23rd Annual Infectious Diseases in Children Symposium; Nov. 20-21, 2010; New York.

Dr. Block is a smart, experienced and skilled pediatrician, so when he speaks (or writes), I listen. His remarks about management of acute otitis media are on target. AOM, particularly in the infant, is a treatable disease, so the key to management is accuracy of otoscopic examination. Otoscopic examination of the infant is a difficult but critical skill for young physicians to master. I rely on one-on-one teaching of medical students with a double-headed otoscope (Welch Allyn) so that the student and teacher make simultaneous observations. Practicing pediatricians may also find the double-headed otoscope of value in comparing examinations with a colleague or demonstrating a finding to a parent. Greater accuracy of diagnosis of AOM equates with less unnecessary prescription of antimicrobial drugs.

– Jerome O. Klein, MD

Infectious Diseases in Children Editorial Board member