Antibiotics for upper respiratory infections

Dr Tocks has correctly pointed out that the duration of the common cold is typically approximately 1 week, although symptoms often persist longer.¹ The 3 cases he presented suggest that at some point the symptoms have been present too long to be a viral URI. This is a question we believe deserves careful study, because it is possible that bacterial infections may be more common among patients with prolonged symptoms of a URI. In the absence of evidence from the medical literature, clinicians will need to practice the art of medicine to decide whether to use antibiotics for patients with URI symptoms lasting longer than 7 to 10 days. Interestingly, in our study duration of symptoms was not independently associated with antibiotic prescribing patterns.

Dr Tocks’s first patient, the 23-year-old woman with a URI, presents an interesting dilemma. First, she clearly has a high probability of acute sinusitis because worsening symptoms after stable or waning symptoms (second sickening), unilateral facial pain, and purulent rhinorrhea have each been associated with acute sinusitis as documented by computed tomography.² Second, the use of an antibiotic (amoxicillin if the patient is not allergic to penicillin) for acute sinusitis is supported by a small number of clinical trials.³ Third, the Centers for Disease Control and Prevention recommend symptomatic treatment before instituting antibiotic treatment for acute uncomplicated sinusitis for patients with mild to moderate symptoms of less than 7 days duration. If she has not been taking a decongestant, should the patient be given a trial of decongestant therapy before starting an antibiotic? We believe that most clinicians would choose to start an antibiotic regardless of whether she had been taking a decongestant. However, this falls under the category of the art of medicine and awaits an evidence-based answer.

Dr Kaufman’s frustration with the lack of clear definitions of the differences and similarities among various viral and bacterial illnesses is understandable. The primary care physicians in the rural primary care research network responsible for the design and execution of this study share this frustration. Hueston and colleagues⁴ have suggested that sinusitis, bronchitis, and URI may all be variations of the same clinical condition (acute respiratory infection) whether viral or bacterial. In 1967, Evans⁵ described the 5 realities of respiratory tract infections: (1) the same clinical condition may be produced by a variety of agents; (2) the same etiologic agent may produce a variety of clinical syndromes; (3) the predominating agent in a given clinical syndrome may vary according to the age group, the year, the geographic location, and the type of population; (4) diagnosis of the etiologic agent is frequently impossible on the basis of the clinical findings alone; and (5) the causes of a large percentage of common infectious disease syndromes are still unknown. His words remain true today. Thus, it appears that our diagnostic understanding of acute respiratory tract infections has progressed very little in the past 3 decades. Faced with these realities physicians choose to prescribe antibiotics for some patients with nonspecific URIs, many patients with bronchitis, and nearly all patients with acute sinusitis. This is true even though many of these illnesses are viral in origin. Clearly, clinicians realize that bacterial infections may cause any of the 3 clinical syndromes of respiratory tract infection.

In the light of the realities of respiratory tract infections, our primary care research group (in the absence of the publish-or-perish mentality of academia) chose to evaluate those factors our clinicians used to justify antibiotic prescriptions, regardless of how they labeled the illness. Presumably the factors we identified are those that our clinicians believe reflect the presence of a bacterial infection whether it is called a URI, sinusitis, or bronchitis. We think that the observational study we presented represents a new and interesting perspective on how clinicians make the decision to prescribe an antibiotic. We also think this study provides a basis for randomized controlled trials to assess whether patients with discolored nasal drainage, rales or rhonchi, postnasal drainage, or sinus tenderness benefit from antibiotics.

Steven Dosh, MD
OSF Medical Group
Escanaba, Michigan

REFERENCES

1. Lauber B. The common cold. J Gen Intern Med 1996; 11:229-36.
2. Lindbaek M, Hjortdahl P, Johnsen UL. Use of symptoms, signs, and blood tests to diagnose acute sinus infection in primary care: comparison with computed tomography. Fam Med 1996; 28:183-88.
3. De Ferranti SD, Ioannidis JP, Lau J, Anninger WV, Barza M. Are amoxicillin and folate inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis. BMJ 1998; 317:632-37.
4. Hueston W, Mainous AG 3rd, Dacus EN, Hopper JE. Does acute bronchitis really exist? J Fam Pract 2000; 49:401-06.
5. Evans A. Clinical syndromes in adults caused by respiratory infection. Med Clin North Am 1967; 51:803-18.