Appropriate Treatment of the Adult Upper Respiratory Infection | March 2021 | Clinical Corner

Appropriate Treatment of the Adult Upper Respiratory Infection

Adult upper respiratory infection (URI) represents one of the most common acute illness seen in the outpatient setting. Adults ages 19 – 39 are diagnosed with 2.2 URI per year and adults 40 and beyond are diagnosed with 1.6 URI per year.(1) In the United States, the annual costs associated with the inappropriate  utilization of antibiotics for treatment of URI in adults and children is $3 Billion dollars.² Inappropriate antibiotic prescribing is at a rate of 40 – 50% for viral respiratory infections.1
Details in the patient’s history may help in distinguishing a “cold” from conditions that require specific therapy. Clinical manifestations may aid in the decision process but may have overlapping physical findings. In patients with URI symptoms, testing for specific viruses and bacteria are useful when certain therapies are dependent on the findings. 
However, for immunocompromised patients or patients with atypical or unusual signs and symptoms, the search for a specific diagnosis or agent of cause may be required. For example, there are certain conditions both bacterial and viral that may require targeted therapy³:

• Epiglottitis – may require intravenous antibiotics, empiric coverage for Haemophilus Influenzae.
• Group A Streptococcus pharyngitis – oral penicillin or amoxicillin.
• Bacterial Rhinosinusitis – most likely pathogens are Streptococcus pneumoniae, Haemophilus Influenzae, Moraxella Catarrhalis.
• Gonococcal pharyngitis – IM ceftriaxone
• Influenza A – zanamivir, oseltamivir
• Cytomegalovirus – ganciclovir.
• Herpes Simplex virus – acyclovir, famciclovir, valacyclovir

To a lay person, “I have a cold, can I get an antibiotic?” is a common request. Although this may be the simplest of conditions, after all, it is only a “common cold”; for the clinician, this is an effortful differential for diagnosis and treatment. There are several important questions to be addressed:

• Is the patient immunocompetent or immunocompromised?
• Do I have a presumptive diagnosis based on the history and physical findings?
• Do I have an accurate diagnosis of a bacterial etiology?
• Do I have a diagnosis requiring targeted therapy?
• If I can confirm a diagnosis or have a presumptive diagnosis of a bacterial etiology, what is the appropriate antibiotic therapy (drug specificity, dose and length of treatment)?

The consequences of inappropriate antibiotics are many – antimicrobial resistance, harm from antibiotic side effects and increase in the health care payer premium. For most patients with upper respiratory infection in immunocompetent adults, they will benefit from reassurance it will get better, education on what it is and suggestions for symptomatic treatment at home.(3) Our ask is to utilize appropriate antibiotic therapy for conditions that require antibiotic medications, and restrain from spontaneous antibiotic script writing for conditions that do not warrant antibiotics. Using those clinician skills to differentiate and treat the Upper Respiratory Infection will provide better outcomes, better utilization of resources and reduce antimicrobial resistance.

References:

1. Hart AM, Patti A, Noggle B, et al. Acute Respiratory infections and antimicrobial resistance. American journal of Nursing. 2008; 108(6):56-65.
2. Harris AM, Hicks LA, Qaseem A, et al. Appropriate antibiotic use for acute respiratory tract infections in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Annals of Internal Medicine. 2016; 164(6):425-434. Doi:10.7326/M15-1840
3. Medscape, Anne Meneghetti M.D., updated September 11, 2020.