Hello. Welcome to the Nebraska Health Network Outpatient Antimicrobial
Stewardship education module presented by Nebraska Medicine and the
Nebraska Antimicrobial Stewardship Assessment and Promotion Program, ASAP.
I'm Jasmine Marcelin, an infectious diseases physician at the University of
Nebraska Medical Center and Associate Medical Director of the Nebraska
Medicine Antimicrobial Stewardship Program. This education module is the
second of a two-part series. In the first presentation we discussed why
antimicrobial stewardship in the outpatient setting matters.
In this presentation we are continuing our conversation about antimicrobial
stewardship in the outpatient setting by focusing on diagnosis and management of
select upper respiratory tract infection syndromes commonly encountered in the
ambulatory clinic practice. Sinusitis is a common diagnosis in the clinic and
initial symptomatic treatment is recommended. In the vast majority of
cases, viruses are responsible. However even when bacteria may be implicated
antibiotics may be recommended but are still not guaranteed to resolve such
symptoms. Therefore when a patient presents with symptoms of URI and
sinusitis the initial recommendation should be symptomatic therapy.
This includes rest, fluids, analgesics, nasal rinses or other conservative approaches.
Sinus radiographs are generally not recommended as they cannot distinguish
between bacterial and viral causes of infection. A good initial strategy is
watchful waiting whereby patients are given parameters for worsening with
instructions for calling back if symptoms do not improve followed by
re-evaluation or phoned in antibiotics if necessary. Now let's walk through a
diagnosis and management algorithm for acute sinusitis. When the patient first
presents with symptoms of sinusitis, assess for persistence, severity or worsening.
If none of these are present the
syndrome is likely viral and a watchful waiting approach can be used. If the
patient has worsening of symptoms is 5 to 7 days they should call to discuss
symptoms and then either be re-evaluated with antibiotics, re-evaluated or treated
with antibiotics. Persistent symptoms may require an office visit or a call in prescription.
If the patient is initially assessed to have persistence, severity or
worsening of symptoms the etiology is possibly bacterial and then antibiotics
may be recommended. In a patient with low risk of being colonized with resistant
organisms and no history of penicillin allergy, oral Augmentin dosed at 875
milligrams twice daily is a reasonable antibiotic choice. If there is a
penicillin allergy, oral doxycycline dosed either 200 milligrams once daily
or 100 milligrams twice daily would be appropriate. If the patient is at high
risk for resistant organisms because of recent antibiotic use, hospitalizations
or is immunocompromised in the absence of penicillin allergy, oral Augmentin
would still be in it would still be appropriate. However this would be at the
higher dose two grams twice daily. If there is a penicillin allergy, oral
levofloxacin dosed 500 milligrams once daily is reasonable. For those providers
who treat children there are published recommendations on use of alternate
regimens for bacterial sinusitis in children with penicillin allergy.
Core treatment principles for management of acute rhinosinusitis are described here.
Of importance, use of azithromycin is discouraged because of increasing
community resistance. Now let's discuss most common diagnosis associated with
a chief complaint of cough in the primary care setting. Acute bronchitis is a
common presenting condition and generally is also caused by viral
pathogens. In fact the American College of Physicians and Centers for Disease
Control and Prevention recommends referring to bronchitis as chest cold to
make an analogy to the common cold for which many patients are aware viruses
are the major cause. However initial evaluation of a patient
with cough should always include review of signs and symptoms to rule out
bacterial pneumonia such as fever, tachycardia, tachypnea or abnormal lung
examination findings which can also present with cough. Patients may often
comment on the color of their sputum and they should be educated that the color
of the sputum does not predict bacterial infection. Chest x-ray is not required to
diagnose bronchitis. Evidence supporting specific symptomatic therapies for acute
bronchitis is limited. However, options include cough suppressants,
first-generation antihistamines and decongestants. There was one study
suggesting that perhaps the combination of these therapies is more beneficial
than either of them alone. We have very strong statements coming from the
American Academy of Family Physicians, the American Academy of Pediatricians,
American College of Physicians and the Centers for Disease Control and
Prevention all emphasizing that antibiotics should not be used to treat
acute bronchitis. The American College of Physicians goes further to state that
even additional testing such as chest x-ray should not be performed unless
pneumonia is suspected. Patients may be concerned because of ongoing cough
and return requesting antibiotics. So it is important to counsel them on diagnosis
that the cough associated with acute bronchitis could last up to six weeks.
Moving on to viral upper respiratory tract illnesses. We can't emphasize this
point more. Antibiotics should not be used for treatment of viral
upper respiratory tract infections. Consider sharing with your patients that
studies have demonstrated significant symptom relief with combination
symptomatic therapy compared to individual therapy. Education is key.
Counsel your patients that their symptoms of runny nose, sore throat,
congestion, even myalgias and cough can last up to two weeks. And symptoms
occurring beyond a few days do not indicate bacterial infection or need for
antibiotics. These may not be easy discussions to have with patients who
request antibiotics and so we have prepared several tools to help you
achieve the goal of improved patient care by reducing antibiotics for acute
viral respiratory syndromes. In addition to this educational module we have
created educational posters reviewing the evaluation and treatment of these
syndromes we discussed today. Also available to you is a clinician
reference pocket card with a quick summary of these guidelines courtesy [of] the
CDC. To facilitate this discussion through patient interaction we can
provide you with pamphlets about non-antibiotic therapies for acute
respiratory infections. Additionally consider discussing with
your electronic health record support staff to locate potential patient
instruction summaries into visit notes for patients to review. These tools are
available upon request through Nebraska ASAP by calling four zero two, five five two,
two eight eight one or visiting the website listed on this slide. Here are
examples of the syndrome specific educational posters available to be
displayed in clinician workspaces as visual reminders of current
recommendations for management of common acute respiratory infections.
Here is an example of a trifold handout specifically designed to assist you as a
clinician with communication. It reviews the common acute respiratory infection
syndromes in plain language for the patient with recommendations for
management. This can be a useful tool for discussion to reinforce with the patient
why antibiotics are not indicated for their illness
and provide them with some reading material if they want a handout after
the visit. These brochures can be made available to any clinic that requests them.
Here is a screenshot of the physician quick access pocket card summarizing the
management strategies for acute respiratory infections in a convenient,
easily accessible pocket card. For free copies of these tools contact ASAP at
four zero two, five five two, two eight eight one or request them through the
website listed on this slide. Please include your mailing address and the
names and quantities of the tools you would like for your clinic. As a reminder
when prescribing antibiotics always remember the ABCs of prescribing. And as
we close this part of the presentation remember that we can all play a part in
preserving the antibiotics we have for future use by being conscious
prescribers and offering alternatives when appropriate. Citations for
guidelines or data quoted in this presentation are listed on individual
slides referencing the information. For any questions regarding antimicrobial
stewardship initiatives in the outpatient setting, feel free to contact
any of our team members listed here. Thank you for viewing this module and
for being antibiotics aware aiming for smart use and best care.