Antibiotics are no longer first-lin...

Antibiotics are no longer first-line treatment for many upper respiratory tract infections. popularly the American Academy of Pediatrics and the American Academy of Family Physicians are promoting strange guidelines for treatment of acute otitis media, proposing that antibiotics not always be used. (12) Similarly, acute bronchitis, which in the past was almost always treated with antibiotics, is now recognized as a viral disease that generally should be treated with solitary supportive methods. (3)

In this issue, Scheid and Hamm current two excellent articles on acute bacterial rhinosinusitis (ABRS). (45) They correctly state that in the greatest degree patients with upper respiratory infections do not have ABRS moreover instead, have viral sinusitis. The question is, by what mode should physicians manage this condition? At this time, physicians are still prescribing antibiotics for in the greatest degree patients whom they diagnose with sinusitis.

As described in Scheid and Hamm's articles, there are numerous methodologically rigorous clinical prediction orders that physicians may use for guidance when examining patients. The question at issue with these guidelines is that they are drawn from studies of patients in subspecialty clinics, and they measure disease-oriented findings documented according to sinus radiographs, computed tomography, and bacterial product from sinus puncture. What family physicians and patients sincerely need to provide guidance is practical or pragmatic clinical trials that proof prediction rules under clinical conditions similar to what actually be met withs in the primary care outpatient setting. (6)

During the office visit, the riddle family physicians face is deciphering which patients will benefit from antibiotics and which uniteds have viral infections and ne and nothing else symptomatic treatment. Any treatment ultimately is based in succession the precept of doing more fit than harm. Family physicians are familiar with this aim because it is at the source of what they do each day while treating patients, if it be not that for some reason this strategy has not been applied consistently in the treatment of upper respiratory infections.

If our goal in treating ABRS was to obstruct serious complications, such as brain abscesses, then we would be willing to treat many patients unnecessarily to stop even one brain abscess. Scheid and Hamm in no degree mention such unlikely complications, and I applaud them for this. This omission forward their part implicitly tells the reader that this is not the real worry of patients and physicians--that, generally, symptomatic improvement is the conformable to fact goal of treatment in patients with ABRS. If our goal is to help something as common and self-limited as corrupt nasal discharge, we may not be willing to treat as many patients to help single in kind because we know that antibiotics will help exceedingly few of them and that nearly sum of two units thirds of patients will continue having symptoms similar as cough and nasal discharge for up to three weeks. (7)

In conjunction with our patients, we ne to decide (1) what our goals are when we clash patients with sinusitis-like symptoms and (2) for what purpose we continue to treat these patients with antibiotics if that treatment does not accomplish our goals. Patient-oriented clinical trials still are destitutioned to identify a subset of patients that are likely to benefit from antibiotic treatment. Meanwhile, it is likely that physicians before long will approach the treatment of ABRS in a fashion similar to that of acute otitis media and bronchitis, and that antibiotics will no longer be the first-line treatment option.

REFERENCES

(1) American Academy of Pediatrics Subcommittee upon Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113:1451-65

(2) Neff MJ AAP, AAFP release guideline onward diagnosis and management of acute otitis media. Am Fam Physician 2004;69:2713-5

(3) Snow V Mottur-Pilson C Gonzales R Principles of appropriate antibiotic use for treatment of acute bronchitis in adults. Ann Intern M 2001;134:518-20

(4) Scheid DC Hamm RM Evaluation of suspected acute bacterial rhinosinusitis in adults: part I. Am Fam Physician 2004;70:1685-92

(5) Scheid DC Hamm RM Evaluation of suspected acute bacterial rhinosinusitis in adults: part II. Am Fam Physician 2004;70:1697-704 1711-12

(6) Tunis SR Stryer DB Clancy CM Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA 2003;290:1624-32

(7) Scott J Orzano AJ. Evaluation and treatment of the patient with acute undifferentiated respiratory tract infection. J Fam Pract 2001;50:1070-7

The Author

DAN MERENSTEIN, MD is Robert grove Johnson Clinical Scholar at John Hopkins University in Baltimore. Address correspondence to Dan Merenstein, MD mate Dept. of Medicine, Robert timber-land Johnson Clinical Scholars Program, 600 N Wolfe St Carnegie 291 Baltimore, MD 21287-6220 (e-mail: dmerenstein@jhu.edu). Reprints are not available from the author.

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