Diagnosis

An accurate diagnosis is the first step in deciding whether an antibacterial drug is needed and selecting the particular drug(s). Antibacterial drugs are frequently prescribed for unexplained fever or vague complaints without a specific diagnosis having been made. Elderly patients, for example, may present only with nonspecific signs of infection, such as fever, fatigue, decreased appetite, mental confusion, or trauma due to a fall. Some patients may benefit from antibacterial therapy, whereas others may receive antibacterial drugs needlessly and risk suffering an ADE. A study of the diagnosis of Lyme disease in children revealed a correct diagnosis in only 51% of 146 patients. Thirty-eight percent were overdiagnosed, whereas a smaller percentage was underdiagnosed for Lyme disease (7). In the southwestern United States, many patients receive antibacterial drugs for treatment of pulmonary coccidioidomycosis. If the correct diagnosis were made, antibacterial therapy could be avoided, and only patients with complications of the primary pulmonary infection would require antifungal treatment (8). Appropriate therapy requires a thorough evaluation of the disease process and knowledge of the clinical entity.

Most of the literature has focused on overuse of antibacterial agents in situations where antibacterial treatment may not provide benefit. Examples of these situations include upper respiratory infection syndromes, acute non-P-hemolytic streptococcal pharyngitis, and acute bronchitis. Data from the 1996 National Ambulatory Medical Care Survey revealed that 61% to 72% of patients diagnosed with a cold, upper respiratory infection, or acute bronchitis were prescribed an antibacterial drug. Such prescriptions accounted for 15% of the total prescriptions for antibacterial drugs (9). Colds, upper respiratory infection syndromes, and acute bronchitis (in adults) are almost always caused by viral infection, and antibacterial therapy does not improve the outcome (10). Although acute sinusitis is frequently managed with antibacterial drugs, most patients have spontaneous resolution of symptoms. A recent placebo-controlled trial of amoxicillin treatment of acute sinusitis did not show a statistically significant improvement with amoxicillin compared with placebo (11). Serious complications associated with acute sinusitis occur primarily in patients who have underlying chronic sinusitis or who are immunocompromised. Antibiotics have only modest benefits in children with acute otitis media or otitis media with effusion. As with acute sinusitis, the spontaneous resolution rate is high. Current recommendations involve waiting 3 to 6 months before considering a trial of antibiotics for otitis media with effusion (12). For acute otitis media in children at least 2 years of age, waiting up to 3 days before initiating antibiotic therapy is a valid treatment option (13,14). Acute otitis media will spontaneously improve in the majority of children, resulting in substantially fewer antibacterial prescriptions. Acute bronchitis is almost always caused by a viral pathogen and is self-limiting without specific therapy. There is no benefit from antibacterial therapy. In contrast to these common respiratory infections, community-acquired pneumonia should be treated with antibacterial agents unless bacterial infection is excluded (15). Influenza is another disease in which antibacterial ther-apy would be inappropriate. Signs, symptoms, and history of influenza vaccination are not reliable to differentiate influenza from other infectious diseases. The availability of a rapid influenza antigen detection test along with white blood cell count has been shown to improve clinical decisions (16). However, the possibility of secondary bacterial pneumonia must be considered in a patient with influenza. When and when not to treat patients for acute exacerbation of chronic bronchitis is less clear than with pneumonia; however, the need for treatment is based on the stage of chronic bronchitis, severity of symptoms, and other risk factors (17).

Dealing With Bronchitis

Dealing With Bronchitis

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