Responsible prescribing for upper respiratory tract infections

Abstract

Upper respiratory tract infections (URTIs) are responsible for a large amount of community antibacterial use worldwide. Recent systematic reviews have demonstrated that most URTIs resolve naturally, even when bacteria are the cause. The high consumer expectation for antibacterials in URTIs requires intervention by the general practitioner and a number of useful strategies have been developed. Generic strategies, including eliciting patient expectations, avoiding the term 'just a virus', providing a value-for-money consultation, providing verbal and written information, empowering patients, conditional prescribing, directed education campaigns, and emphasis on symptomatic treatments, should be used as well as discussion of alternative medicines when relevant. The various conditions have differing rates of bacterial infection and require different approaches. For acute rhinitis, laryngitis and tracheitis, viruses are the only cause and, therefore, antibacterials are never required. In acute sore throat (pharyngitis) Streptococcus pyogenes is the only important bacterial cause. A scoring system can help to increase the likelihood of distinguishing a streptococcal as opposed to viral infection, or alternatively patients should be given antibacterials only if certain conditions are fulfilled. Strategies for treating acute otitis media vary in different countries. Most favour the strategy of prescribing antibacterials only when certain criteria are fulfilled, delaying antibacterial prescribing for at least 24 hours. In otitis media with effusion, on the other hand, there is no primary role for antibacterials, as the condition resolves naturally in almost all patients aged >3 months. Detailed strategies for acute sinusitis have not been worked out but restricting antibacterial prescribing to certain clinical complexes is currently recommended by several authorities because of the high natural resolution rate.

Table I

Patient information material on upper respiratory tract infections available on websites

Table II

Reduction in prescriptions after educational intervention (adapted from Rogers & Light[14])

Fig. 1

Scoring method to improve the likelihood of distinguishing viral from streptococcal infection. From McIsaac et al.[24] by permission of the publisher. ^©1998 Canadian Medical Association (http://www.cma.ca).

Table III

Australian recommendations for the treatment of acute pharyngitis

Table IV

Dutch guidelines for the treatment of acute otitis media

Table V

When to treat acute sinusitis