Jerome R. Hoffman

Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background

1.0 Background Sore throat is one of the most common chief complaints of adults treated in an outpatient setting. Although its differential diagnosis is large and includes many other causes that are important to recognize (Table), the vast majority of immunocompetent adults presenting with sore throat have acute infectious pharyngitis. Most of the widespread antibiotic use in such patients is based on an effort to treat bacterial (particularly streptococcal) pharyngitis. Recognition and specific treatment of some of these other sore throat entities are important but are beyond the scope of this paper, which addresses the treatment of nongonococcal, nondiphtherial acute pharyngitis in healthy adults. Table. Differential Diagnosis of Sore Throat in the Immunocompetent Adult 1.1 Acute pharyngitis accounts for 1% to 2% of all visits to outpatient departments, physician offices, and emergency departments (1). A wide range of infectious agents, most commonly viruses, cause acute pharyngitis. Approximately 5% to 15% of cases in adults are caused by group A -hemolytic streptococcus (GABHS) (2-7). In some patients, it can be important to identify an infectious cause other than GABHS (for example, gonococcal pharyngitis, EpsteinBarr virus, and acute HIV infection), but in the vast majority of cases, acute pharyngitis in an otherwise healthy adult is self-limited and rarely produces significant sequelae. 1.2 Antibiotics are prescribed to a substantial majority (approximately 75%) of adult patients with acute pharyngitis (8). Physicians report that they prescribe unwarranted antibiotics because they believe that patients expect them, that patients will reconsult if antibiotics are not prescribed, that patients will be unsatisfied without a prescription, and that it is quicker to write a prescription than to explain why a prescription is not indicated (9-11). However, physicians are not very good at predicting which patients expect antibiotics (11, 12), and patient satisfaction depends less on whether an antibiotic is prescribed, or even whether preconsultation expectations are met, than on whether the physician shows concern and provides reassurance (9, 11-15). Delaying antibiotic prescriptions does not increase the chance that patients will return in the next few days for reconsultation. Prescribing antibiotics medicalizes the illness, and one study found increased likelihood that patients would return for the next similar illness (13, 15, 16). The inappropriate use of antibiotics can have significant negative consequences both to individual patients and to public health. Goals This paper examines the available evidence regarding the diagnosis and treatment of acute GABHS pharyngitis in adult patients. It makes recommendations that balance concerns about the potential consequences of untreated GABHS and the goal of decreasing inappropriate antibiotic prescriptions. It discusses pharyngitis in adults (patients 18 years of age), a population in which GABHS accounts for only approximately 5% to 15% of cases (2-7) and in which such complications as acute rheumatic fever are much less common. These guidelines do not apply to patients with a history of rheumatic fever, valvular heart disease, immunosuppression, or recurrent or chronic pharyngitis (symptoms > 7 days), or to patients whose sore throats have a cause other than acute infectious pharyngitis. They are not intended to apply during a known epidemic of acute rheumatic fever or streptococcal pharyngitis or in nonindustrialized countries in which the endemic rate of acute rheumatic fever is much higher than in the United States. Clinicians should always consider the epidemiologic circumstances when applying these recommendations in practice. Furthermore, these principles are not intended to comment on or contradict previous practice guidelines from other organizations (17, 18), which are primarily directed at sore throat evaluation in children. 2.0 Methods We conducted a systematic review of the literature from 1950 to 2000 for these evidence-based management principles. We identified all randomized, controlled trials or meta-analyses of randomized, controlled trials that contained clear definitions of criteria for inclusion, diagnosis, and outcomes, as well as studies evaluating diagnostic strategies for GABHS pharyngitis. We searched MEDLINE and the Cochrane Library, and we also searched the references of the inception articles to identify other studies. Our search strategy sought English-language articles and used the keywords sore throat, group A streptococcus, pharyngitis, tonsillitis, streptococcal pharyngitis, throat culture, and strep. Many of the identified articles had easily recognizable methodologic flaws (for example, use of convenience samples, exclusion of patients without a throat culture or those without a positive throat culture, and lack of an appropriate or clearly identified criterion standard), and we considered these limitations when evaluating the evidence and making our recommendations. Furthermore, the efficacy reported in the clinical trials may have been affected in part by repeated clinic visits, repeated cultures, and checks of patient adherence to pill ingestion, all of which would result in overestimation of the effect size of treatment. We did not mathematically summarize the various trials because of the variable quality of the cited evidence. 3.0 Evidence for Antibiotic Treatment of Pharyngitis Caused by GABHS Pharyngitis caused by GABHS is predominantly a disease of children 5 to 15 years of age. It has a prevalence of approximately 30% in pediatric pharyngitis but only 5% to 15% in adult pharyngitis in nonepidemic conditions (2-7, 19, 20). Physicians may consider prescribing antibiotics for streptococcal pharyngitis to prevent rheumatic fever, prevent acute glomerulonephritis, prevent suppurative complications, decrease contagion, and relieve symptoms. 3.1 Acute Rheumatic Fever Early randomized trials demonstrated that penicillin treatment of streptococcal pharyngitis is effective in preventing acute rheumatic fever (21-23) (relative risk, 0.28 [24]). This translated into a number needed to treat for benefit (NNTB) of approximately 63 to prevent one case of acute rheumatic fever in the samples studied. These early trials were usually performed in populations with a much higher incidence of acute rheumatic fever in both the treated and control groups than is present today. The reported incidence per population was approximately 60 times greater in 1965 than in 1994 (the last year for which the Centers for Disease Control and Prevention reported statistics); therefore, the NNTB today is undoubtedly much higher, in the range of approximately 3000 to 4000 (25-27). Carditis is the most serious complication associated with acute rheumatic fever. In recent outbreaks of acute rheumatic fever, carditis was seen in 50% to 91% of pediatric cases (28-31). These data probably reflect diagnosis of subclinical cases by echocardiography. Carditis occurred in approximately one third of adult cases of acute rheumatic fever (32, 33). The most important consequence of carditis, permanent valvular dysfunction, is most common after clinically severe carditis (28). Given that acute rheumatic fever is rare in adults, that carditis is not a common feature of adult cases of acute rheumatic fever, and that most cases of carditis in adults are mild or asymptomatic, the likelihood of permanent cardiac dysfunction seems to be very small. Thus, the NNTB to prevent a single case of clinically significant carditis is substantially greater than the NNTB to prevent a single case of acute rheumatic fever. During the 1980s, several outbreaks of acute rheumatic fever occurred, causing concern about reemergence of the disease (29-32, 34, 35). It is important to consider local epidemics. Physicians should be prepared to revise their treatment approaches if evidence suggests an outbreak. 3.2 Acute Glomerulonephritis Although poststreptococcal acute glomerulonephritis occurs, it is extremely rare, even in the absence of antibiotic treatment (36-41). Furthermore, no evidence shows that antibiotic therapy for pharyngitis decreases the incidence of this complication (36-41). 3.3 Peritonsillar Abscess The incidence of suppurative complications, regardless of treatment with antibiotics, is also low (42-45). A review of randomized trials from the 1950s and 1960s indicates that antibiotics decrease the incidence of peritonsillar abscess (quinsy) complicating streptococcal pharyngitis (24), with a best estimate for NNTB of 27. Modern clinical trials (44, 45) provide some evidence that targeting antibiotics to a subset of patients with higher clinical likelihood of GABHS may prevent peritonsillar abscess. However, in another recent review of GABHS pharyngitis in practice, Little and Williamson (46) reported that the risk for peritonsillar abscess was not reduced because many patients did not present for care until after the complication had developed (46). A recent retrospective study of more than 30 000 patients confirms these findings (47). Among patients who developed suppurative complications, 31 of 71 (44%) had them at first presentation (47). Of the other 56% who presented with pharyngitis before subsequent development of peritonsillar abscess, only approximately 25% showed GABHS on culture or rapid antigen test, and most (67%) had been treated with antibiotics that effectively eradicated GABHS. 3.4 Prevention of Spread of Disease Streptococcal infection often occurs in epidemics, and contagion is a problem in areas of overcrowding or close contact. Although treatment must continue for 10 days, 24 hours of antibiotic therapy greatly reduces the recovery of GABHS from pharyngeal cultures (41, 48-50). While antibiotics are recommended as a means of reducing spread in schools and other closed settings (20), the impact of treatment on disease spread in noninstitutionalized adult po

Selective Cervical Spine Radiography in Blunt Trauma: Methodology of the National Emergency X-Radiography Utilization Study (NEXUS)

Fear of failure to identify cervical spine injury has led to extremely liberal use of radiography in patients with blunt trauma and remotely possible neck injury. A number of previous retrospective and small prospective studies have tried to address the question of whether any clinical criteria can identify patients, from among this group, at sufficiently low risk that cervical spine radiography is unnecessary. The National Emergency X-Radiography Utilization Study (NEXUS) is a very large, federally supported, multicenter, prospective study designed to define the sensitivity, for detecting significant cervical spine injury, of criteria previously shown to have high negative predictive value. Done at 23 different emergency departments across the United States and projected to enroll more than 20 times as many patients with cervical spine injury than any previous study, NEXUS should be able to answer definitively questions about the validity and reliability of clinical criteria used as a preliminary screen for cervical spine injury.

Principles of Appropriate Antibiotic Use for Treatment of acute respiratory Tract Infections in adults: Background, specific aims, and methods

Background The Need To Improve Antibiotic Prescription for Acute Respiratory Infections 1. The epidemic increase in antibiotic-resistant Streptococcus pneumoniae is an ambulatory care problem. Excessive use of antibiotics in ambulatory practice has contributed to the emergence and spread of antibiotic-resistant bacteria in the community (1-4). Penicillin resistance in S. pneumoniae has increased in an epidemic manner in the past 10 years (5, 6). Resistance to macrolides, doxycycline, trimethoprimsulfamethoxazole, and second- and third-generation cephalosporins has also increased. Special attention to antibiotic-resistance profiles of S. pneumoniae is warranted, since this pathogen is the leading cause of community-acquired bacterial pneumonia, bacterial meningitis, bacterial sinusitis, and otitis media in the United States (7). 2. Previous antibiotic use is an important risk factor for carriage of and infection with antibiotic-resistant Streptococcus pneumoniae. The major risk factors for carriage of and infection with antibiotic-resistant S. pneumoniae are geographic location, recent exposure to antibiotics, and exposure to young children. Carriage of S. pneumoniae (and antibiotic-resistant S. pneumoniae) primarily occurs in the nasopharynx and oropharynx of susceptible hosts (8, 9). Factors contributing to the spread of S. pneumoniae (such as close contact and viral respiratory infections) are also associated with the spread of antibiotic-resistant S. pneumoniae (10-12). For example, carriage and transmission of antibiotic-resistant S. pneumoniae are greatest during winter months and in environments that facilitate the transmission of respiratory secretions (8). The prevalence of carriage of S. pneumoniae and antibiotic-resistant S. pneumoniae appears to be greatest in young children; up to one third of children who visit health clinics are reported to be nasopharyngeal carriers of antibiotic-resistant S. pneumoniae (13-15). The prevalence of S. pneumoniae colonization in the upper airways in adults is about 5%; this value increases if children are present in the household (10). Although the risks for transmission of antibiotic-resistant S. pneumoniae mirror those for S. pneumoniae, numerous retrospective and prospective carriage studies have also identified previous antibiotic use, especially for a prolonged period (for example, as prophylaxis against recurrent acute otitis media), to be the most significant risk factor for carriage and subsequent spread of antibiotic-resistant S. pneumoniae (14-18). The risk for carriage of antibiotic-resistant S. pneumoniae is two to nine times greater in persons who have recently used antibiotics. A precipitously rapid increase in antibiotic resistance has also been observed for strains of S. pneumoniae in blood, cerebrospinal fluid, and joint fluid in the United States since 1986, when invasive antibiotic-resistant S. pneumoniae isolates were rare or absent (5). Like carriage of antibiotic-resistant S. pneumoniae, invasive infection with antibiotic-resistant S. pneumoniae is associated with previous antibiotic use (6, 19-22). When invasive infection with antibiotic-resistant S. pneumoniae occurs, antibiotics with poor central nervous system penetration and bacteriostatic (instead of bactericidal) properties must sometimes be used. Treatment failures have been reported in patients with pneumococcal meningitis after therapy with penicillin, chloramphenicol, clarithromycin, ceftriaxone, and cefotaxime (12, 23-26). The management of outpatient bacterial infections, such as acute otitis media, becomes substantially more difficult because of high rates of antibiotic-resistant S. pneumoniae in children with such infections (27, 28). However, few studies have quantified the clinical impact of antibiotic-resistant S. pneumoniae on morbidity, mortality, and health care costs in children or adults. In a study of hospitalized patients with severe pneumococcal pneumonia in Spain, where a high prevalence of antibiotic-resistant S. pneumoniae preceded the current increase in the United States, no association was seen between antibiotic resistance and mortality (29). However, most patients had intermediate-level penicillin resistance; in such patients, serum and lung interstitium concentrations of antibiotic are sufficiently high to overcome resistance. A recent study of U.S. adults hospitalized with community-acquired pneumonia due to S. pneumoniae found that mortality was significantly associated with high-level antibiotic-resistant S. pneumoniae (minimum inhibitory concentration 4 g/mL), after exclusion of deaths that occurred within the first 2 to 4 days of hospitalization (30). Exclusion of early deaths is justified, since antibiotic therapy has not been shown to affect early mortality in adults with antibiotic-susceptible pneumococcal disease (31). Because of the current increase in antibiotic resistance in community bacterial pathogens, many experts are predicting an impending postantibiotic era (2-4). 3. Most antibiotic prescriptions in the ambulatory setting are for acute respiratory infections. Intervention strategies aimed at reducing community use of antibiotics must address the management of acute respiratory infections. These illnesses are the most frequent reasons for seeking medical attention in the United States, and they are associated with up to 75% of total antibiotic prescriptions each year (32). Transmission of S. pneumoniae is enhanced during viral acute respiratory infection through increased respiratory and nasal secretions (10). As a result, antibiotic treatment of viral acute respiratory infections is particularly problematic, since it may selectively promote the acquisition and spread of antibiotic-resistant bacteria by patients. Specific acute respiratory infections that must be targeted for reducing unnecessary antibiotic use in adults are uncomplicated acute bronchitis (not including acute exacerbations of chronic bronchitis), acute sinusitis, pharyngitis, and nonspecific upper respiratory tract infection (including the common cold). These diagnoses are usually made in the presence of a clinical syndrome with a predominant clinical feature, so that prominent acute cough is taken to mean acute bronchitis, prominent nasal and sinus symptoms are thought to signify sinusitis, and prominent acute sore throat is considered pharyngitis. Acute respiratory symptoms in the absence of a predominant symptom are typically diagnosed as upper respiratory tract infection. Each of these syndromes can be caused by a multitude of different viruses and, on occasion, bacteria. The degree of excess prescription of antibiotics varies for each diagnosis. Antibiotic treatment of a cold, an upper respiratory tract infection, or acute bronchitis is almost always inappropriate because the vast majority of these syndromes have a nonbacterial cause. Antibiotic treatment of sinusitis and pharyngitis is sometimes justified but should be limited to appropriate subsets of patients. Potential Benefit and Harm of Adherence to Principles of Appropriate Antibiotic Prescription Potential Benefits of Indiscriminant Antibiotic Prescription Some clinicians may prescribe antibiotics because they believe that a very small fraction of patients might benefit or they hope to prevent the remote case of a bad outcome (and a potential lawsuit). A theoretical clinical benefit of treating viral respiratory tract infections with antibiotics cannot be excluded. A truism for all clinical trials performed in medicine is that a benefit of treatment cannot be excluded for outcomes that occur less frequently than the sample size can detect (that is, there will always be specific outcomes that were not or cannot be measured). For example, invasive bacterial disease, such as sepsis or bacterial meningitis, is too rare an event to be evaluated in a randomized, controlled trial with enough power to exclude a potential benefit of antibiotic treatment. The incidence of bacterial meningitis in the United States is about 3 per 100 000 persons in the general population (1995) (33) or about 9 per 100 000 persons with an office visit for an acute respiratory illness (unpublished data based on the National Ambulatory Medical Care Survey, 1997). Indiscriminant use of antibiotics may also in theory prevent complications of other undiagnosed bacterial infections, such as acute rheumatic fever. While these hypothetical benefits are possible, no evidence supports their existence. Potential Harms of Indiscriminant Antibiotic Prescription In contrast to the theoretical clinical benefit of indiscriminant prescription of antibiotics, the potential harm of this practice is well established at the level of the patient and society. At the patient level, risks include allergic reactions (such as urticaria, rash, and anaphylaxis), adverse reactions (such as gastrointestinal discomfort or yeast infections), and drugdrug interactions (such as QT interval prolongation caused by warfarin and oral contraceptives), as well as the increased likelihood that a pneumococcal infection in the ensuing months will be due to an antibiotic-resistant strain. At the societal level, the adverse effects of indiscriminant antibiotic use on rates of antibiotic resistance are well established, and the effects on health care costs (for antibiotics and office visits) are straightforward. Finally, indiscriminant antibiotic use could serve to inappropriately medicalize viral illnesses. This tendency not only usurps the ability of individual persons to care for self-limited illnesses but also carries large associated costs in terms of unnecessary office visits and prescriptions. Potential Benefits of Limiting Indiscriminant Antibiotic Prescription Besides decreasing the risk for the harms noted above, the intended result of efforts to decrease indiscriminant antibiotic use in the ambulatory setting is to reduce (and preferably reverse) the increase in antibiotic-re

Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background.

1.0 The excessive use of antibiotics in ambulatory practice has contributed to the emergence and spread of antibiotic-resistant bacteria (1-2, 4). Antibiotic treatment of common respiratory infections accounts for a large percentage of this excessive use. Rhinosinusitis is one of the 10 most common diagnoses in ambulatory practice and is the cause of an estimated 25 million U.S. physician office visits in 1995 (5). Fourteen percent of Americans claim to have had a previous diagnosis of sinusitis (6), but the term sinusitis typically has a different meaning for patients and for primary care physicians. When patients say I have sinus trouble, they usually describe acute or chronic symptoms, such as headache, facial pain, nasal congestion, or rhinorrhea, each of which may be due to a variety of causes. Primary care physicians tend to think of sinusitis as an acute bacterial infection, for which they prescribe an antibiotic in 85% to 98% of cases (7, 8). According to data from the National Ambulatory Medical Care Survey, sinusitis is the fifth most common diagnosis for which an antibiotic is prescribed (9). However, sinusitis is frequently caused by viral infection and will resolve in most patients without antibiotic treatment. These principles present an argument for a conservative approach to use of antibiotics in patients with sinusitis-like symptoms, consistent with efforts to reduce antibiotic use for respiratory infections in ambulatory patients. Background, rationale, and methods used for development of these principles have been published separately (10). 1.1 The term sinusitis refers to inflammation of the mucosa of the paranasal sinuses, regardless of cause. Because sinusitis is invariably accompanied by inflammation of the contiguous nasal mucosa, rhinosinusitis has become the preferred term. Most cases of rhinosinusitis involve more than one of the paranasal sinuses, most commonly the maxillary and ethmoid sinuses. Isolated infection of a frontal or sphenoid sinus is a rare and potentially dangerous condition, usually caused by bacteria, which presents very differently from the vast majority of cases of rhinosinusitis seen in primary care. Patients with this type of infection seem seriously ill and may show signs of cavernous sinus thrombosis or meningitis. Diagnosis and treatment of isolated frontal and sphenoid sinusitis are beyond the scope of this discussion. For purposes of diagnosis and treatment, rhinosinusitis is classified as acute (symptom duration < 4 weeks), subacute (symptom duration 4 to 12 weeks), and chronic (symptom duration > 12 weeks) (11). Patients may have recurrent acute attacks or acute exacerbations of chronic rhinosinusitis. Chronic and subacute bacterial sinus infections may require surgical consultation and management. Acute rhinosinusitis, however, makes up most cases in ambulatory care, and primary care clinicians treat most of these infections without consultation. These principles are limited to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in immunocompetent adults. 1.2 Acute bacterial rhinosinusitis is usually a secondary infection resulting from sinus ostia obstruction or impairment of mucus clearance mechanisms caused by an acute viral upper respiratory tract infection (12). Streptococcus pneumoniae and Haemophilus influenzae are the bacteria most commonly isolated from infected maxillary sinuses (13). Streptococcus pyogenes, Moraxella catarrhalis, and anaerobic bacteria each account for a small percentage of bacterial sinus infections. Current reviews providing more details of the pathogenesis of acute and chronic sinusitis have recently been published (11, 13). The gold standard for diagnosis of bacterial rhinosinusitis is sinus puncture with aspiration of purulent secretions that yield growth on culture of at least 105 organisms per milliliter of a likely respiratory pathogen (14). However, sinus puncture is an invasive procedure seldom performed in primary care and is usually indicated only in complicated cases, such as those resistant to treatment. Because no simple and accurate office-based tests for acute bacterial rhinosinusitis are available, clinicians rely on clinical findings to make the diagnosis. However, signs and symptoms of acute bacterial rhinosinusitis and of prolonged viral upper respiratory tract infections are extraordinarily similar, making the clinical diagnosis of acute bacterial rhinosinusitis difficult and resulting in frequent misclassification of viral cases. Antibiotics have potential value in treating acute rhinosinusitis only when true bacterial infection is present. Therefore, two issues must be addressed before use of antibiotics is considered for acute rhinosinusitis. First, can one reliably differentiate acute bacterial rhinosinusitis from acute viral rhinosinusitis and, if so, how? Second, are antibiotics effective in treatment of acute bacterial rhinosinusitis and, if so, how effective? Principles Principle 1. Most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections [A]. (Letters in square brackets are evidence ratings. See the background document in this issue [10] for explanation.) 2.0 Causes of acute sinus inflammation include infection, allergy, and local irritants. Cases due to allergy and irritants can usually be distinguished from infection on the basis of a careful history. Symptoms due to allergy and environmental irritants are usually more chronic or recurrent, are infrequently associated with purulent nasal discharge, frequently include itching and sneezing, and are often associated with specific exposures. Adult patients are often accurate in self-diagnosis of allergic rhinitis (15). Infectious causes of acute rhinosinusitis include respiratory viruses, fungi, and bacteria. Fungal infections are rare in immunocompetent hosts. Viruses cause most cases of acute sinus inflammation. Maxillary sinus radiographs of young adults with typical viral upper respiratory tract infections showed mucosal abnormalities in 39% of cases on the seventh day of illness (16), and computed tomographic scans were abnormal in 87% of similar cases (17). These studies show that some degree of sinus mucosa inflammation is very common in viral upper respiratory tract infections. On the basis of epidemiologic estimates, only 0.2% to 2% of viral upper respiratory tract infections in adults are complicated by bacterial rhinosinusitis (18, 19), and approximately 15% of people with symptoms of acute respiratory infection seek medical care (20). Presuming a 2% bacterial rhinosinusitis infection rate, if all patients with bacterial rhinosinusitis were among those seeking care, no more than approximately 13% (0.02/0.15) of patients who presented with symptoms of acute respiratory infection would have bacterial rhinosinusitis. Yet the ratio of cases in which primary care physicians diagnose upper respiratory tract infection and acute rhinosinusitis in adults is approximately 1:1 (7, 8), suggesting that clinicians frequently misclassify viral upper respiratory tract infections as acute bacterial rhinosinusitis. Principle 2. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds [B]. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especially when unilateral) and purulent nasal secretions. Patients who have rhinosinusitis symptoms for less than 7 days are unlikely to have bacterial infection. 3.0 Overdiagnosis of acute bacterial rhinosinusitis is not surprising, considering the lack of specific clinical features that distinguish it from nonbacterial upper respiratory tract infections. Relying on overall clinical impression, primary care physicians classifying patients as highly likely to have bacterial rhinosinusitis are correct in approximately 40% to 50% of cases (18-22). Often, patients and physicians believe that an upper respiratory tract infection has gone on for too long and that antibiotic treatment is therefore needed. Gwaltney and colleagues (21) studied the natural history of rhinovirus illness in young adults. Length of illness ranged from 1 to 33 days, and only one fourth of the patients had symptoms lasting longer than 14 days. Most were well or nearly well in 7 to 10 days. However, in clinical trials of diagnosis and treatment of rhinosinusitis, duration of illness alone does not reliably distinguish prolonged viral infection from bacterial rhinosinusitis (Williams J, Hansen JG, Lindbaek M. Personal communication). For example, Lindbaek found that, among patients with sinusitis-like symptoms referred from primary care physicians, 80% of those with computed tomography criteria for bacterial sinusitis (air-fluid level or total opacification) had had symptoms for longer than 7 days, while 70% of those without computed tomography criteria for bacterial rhinosinusitis also had symptoms for more than 7 days. Nonetheless, bacterial rhinosinusitis was seen in only 20% of patients whose symptoms lasted less than 7 days (Lindbaek M. Personal communication). Therefore, duration of symptoms of 7 days or greater is a moderately sensitive but nonspecific predictor of bacterial rhinosinusitis. 3.1 Aside from duration of illness, are any symptoms and signs helpful in distinguishing between bacterial and viral rhinosinusitis? Since 1976, seven investigators have published reports attempting to identify signs and symptoms specific to acute bacterial rhinosinusitis (22-28). All seven studies are limited by use of imperfect diagnostic standards. None used the best criterion for diagnosing bacterial rhinosinusitis, which is aspiration of purulent secretions on sinus puncture that grow at least 105 organisms per milliliter of a likely respiratory pathogen on culture. The findings of

Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults

In this guideline, we present the evidence and make specific recommendations on how clinicians can distinguish and diagnose pharyngitis caused by group A -hemolytic streptococcus (GABHS). We also discuss when antibiotic use is beneficial and which antibiotics should be used. This guideline will not cover gonococcal pharyngitis and diphtheria, for which the appropriateness of immediate antibiotic treatment is well established. The numbers in square brackets are cross-references to the numbered sections in the accompanying background paper, Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background, which is part 2 of this guideline (see pages 509-517). Acute Pharyngitis Acute pharyngitis accounts for 1% to 2% of all visits to outpatient departments, physician offices and emergency departments. A wide range of infectious agents produces acute pharyngitis, but viruses are the most common cause. Approximately 5% to 15% of adult cases are caused by GABHS. In some patients, it can be important to identify an infectious cause other than GABHS (for example, gonococcal pharyngitis, EpsteinBarr virus, and acute HIV infection), but in the vast majority of cases, acute pharyngitis in an otherwise healthy adult is self-limited and rarely produces significant sequelae [1.1]. Antimicrobial agents are prescribed to a substantial majority of patients with acute pharyngitis because of perceived patient expectations or physician desires to avoid such potential complications as rheumatic fever and acute glomerulonephritis. Consequently, this discussion will focus on the diagnosis and treatment of acute GABHS pharyngitis in adult patients. These guidelines do not apply to patients with a history of rheumatic fever, valvular heart disease, immunosuppression, or recurrent or chronic pharyngitis (symptoms > 7 days) or to patients whose sore throats are not due to acute pharyngitis. They are also not intended to apply during a known epidemic of acute rheumatic fever or streptococcal pharyngitis, or in nonindustrialized countries in which the endemic rate of acute rheumatic fever is much higher than in the United States [1.2]. Although it has been more than 50 years since treatment of streptococcal pharyngitis with penicillin was shown to prevent acute rheumatic fever, diagnosing GABHS infection remains a subject of controversy. This is in part because the best criterion standard for the diagnosis has not been definitively established, and testing for a significant increase in antistreptolysin titers and use of throat swab cultures cannot provide real-time resultsthat is, results that are available when a decision regarding antibiotic use must be made. Because only patients with GABHS (and a few other rare bacterial agents) benefit from antimicrobial therapy, the goal of the diagnostic evaluation should be to predict which patients have a high likelihood of GABHS pharyngitis. Diagnosis Although recovery of GABHS from throat cultures is reported in many clinical trials and may be the best available predictor of treatment response, it has poor testretest agreement; does not always correlate with antistreptolysin titers; and produces results that vary depending on technique, the site in which the sample is obtained and plated, the culture medium, the conditions in which the culture is incubated, and whether results are checked at 24 or 48 hours. Throat cultures also fail to distinguish acute infection from the carrier state. Furthermore, because culture results are not available at the time of the index visit, and a delayed decision about use of antibiotics eliminates the primary benefit of antimicrobial therapy in adults (symptom relief), we do not include use of throat culture for clinical decision making in this set of management principles. In addition, there are several reasonable approaches to the diagnosis of GABHS in an otherwise healthy adult, such as use of clinical criteria alone or use of rapid antigen testing as an adjunct to clinical screening. Either of these strategies is associated with reasonable diagnostic accuracy (approximate sensitivity 70%, specificity 70%) and allows treatment decisions to be made early in the course of illness, when patients can receive symptomatic benefit [4.04.2]. Although use of clinical screening (history and physical examination) alone would leave some patients with GABHS untreated and would result in overtreatment of others, it would prompt treatment of most patients with GABHS while dramatically decreasing excess antibiotic use. The most reliable predictors include tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough, and history of fever. Several studies examining these four criteria in a clinical decision rule indicate that in patients who have three or four of the criteria, the sensitivity and specificity (compared with those of throat culture) are approximately 75% and 75%, respectively [4.2.1]. Rapid antigen tests for GABHS, when compared with the criterion standard of throat culture, have widely variable reported sensitivity (58% to 96%) and specificity (63% to 100%), depending on the type of test and practice setting of the trial. These rapid antigen tests can be done at the bedside, and treatment decisions can be made in real time. The potential advantage of the rapid antigen tests compared with clinical models is that they have approximately the same sensitivity and perhaps greater specificity for predicting results of throat culture. The disadvantage is that many patients would need to be tested to achieve the possible gain in specificity beyond that provided by clinical information alone. This would shift economic costs from a few extra prescriptions to many extra rapid antigen tests. Performing rapid antigen testing only in individual patients with an intermediate clinical probability of GABHS (those with three, or perhaps two, of the four clinical variables) and withholding antimicrobial agents from those with negative results would decrease antimicrobial use, compared with a clinical decision alone, at the cost of potentially undertreating an additional small group of patients with GABHS. Unfortunately, although many physicians currently perform rapid antigen tests, there is evidence that they frequently prescribe antimicrobial agents even when test results are negative [4.2.2]. Treatment Reasons to consider prescribing antimicrobials to treat streptococcal pharyngitis include a desire to prevent rheumatic fever, prevent acute glomerulonephritis, prevent suppurative complications, decrease contagion, and ameliorate symptoms. Although reported rates may underestimate the true incidence of acute rheumatic fever, repeatedly low and unchanging reported rates over more than a decade prompted the Centers for Disease Control and Prevention to drop acute rheumatic fever from active national surveillance in 1994. It is still important to consider local epidemics and to be prepared to revise the approach to treatment if evidence of an outbreak exists, although the number of discrete outbreaks of acute rheumatic fever in the United States is very small and should not overly influence physician behavior. Similarly, poststreptococcal acute glomerulonephritis does occur but is extremely rare, even in the absence of antibiotic treatment. Furthermore, there is no evidence that antimicrobial therapy decreases incidence of this complication [3.0, 3.1]. The incidence of suppurative complications, regardless of treatment with antimicrobials, is also small. The most common complication today is peritonsillar abscess (quinsy). Recent clinical trials provide some evidence that targeting antimicrobials to a subset of patients with higher clinical likelihood of GABHS may prevent quinsy. In another recent review of GABHS pharyngitis in practice, however, the authors reported that the risk for peritonsillar abscess was not reduced because many affected patients do not present for care until after the complication has developed [3.2, 3.3]. Streptococcal infection often occurs in epidemics, and contagion is a problem in areas of overcrowding or close contacts. Antimicrobial agents lead to far greater microbiological eradication of streptococcus by 48 to 72 hours. However, the presymptomatic incubation period for GABHS is 2 to 5 days, during which the infection can be unknowingly transmitted to others. The effect of treatment on spread of disease in a noninstitutionalized adult population is unknown. Nevertheless, it is not unreasonable to consider whether an adult is living in close quarters with small children when making clinical decisions about treatment [3.4]. The relief of patient suffering is an appropriate concern of physicians as well as patients. Antimicrobial agents, when instituted within 2 to 3 days of symptom onset, hasten symptomatic improvement among patients in whom throat culture ultimately grows GABHS or in populations in which a high likelihood of GABHS pharyngitis is identified clinically, but not in those with a negative culture. Symptoms seem to resolve 1 to 2 days sooner when antipyretics and other comfort measures are also instituted. One recent trial among unselected patients with acute pharyngitis found that symptom duration was strongly related to patient satisfaction, and patient satisfaction was closely related to whether the physician addressed the patients concerns rather than to use of antibiotics. This further supports limiting antimicrobials to the subset of patients most likely to benefit and reemphasizes the importance of the quality of the physicianpatient interaction [3.5]. If antimicrobial treatment is to be instituted, physicians should choose an agent with the narrowest possible spectrum of action that still covers GABHS. Thus, penicillin is the first choice for patients without a penicillin allergy, and erythromycin is the first choice for penicillin-allergic patients. To date, there is no evidence of GABHS res

Is the use of pan-computed tomography for blunt trauma justified? A prospective evaluation.

OBJECTIVE Many trauma centers use the pan-computed tomography (CT) scan (head, neck, chest, and abdomen/pelvis) for the evaluation of blunt trauma. This prospective observational study was undertaken to determine whether a more selective approach could be justified. METHODS We evaluated injuries in blunt trauma victims receiving a pan-CT scan at a level I trauma center. The primary outcome was injury needing immediate intervention. Secondary outcome was any injury. The perceived need for each scan was independently recorded by the emergency medicine and trauma surgery service before patients went to CT. A scan was unsupported if at least one of the physicians deemed it unnecessary. RESULTS Between July, 1, 2007, and December, 28, 2007, 284 blunt trauma patients (average Injury Severity Score = 11) underwent a pan-CT after the survey form was completed. A total of 311 CT scans were judged to be unnecessary in 143 patients (27%), including scans of the head (62), neck (50), chest (116), and abdomen/pelvis (83). Of the 284 patients, 48 (17%) had injuries on 52 unsupported CT scans. An immediate intervention was required in 2 of the 48 patients (4%). Injuries that would have been missed included 5 of 62 unsupported head scans (8%), 2 of 50 neck scans (4%), 33 of 116 chest scans (28%), and 12 of 83 abdominal scans (14%). These missed injuries represent 5 of the 61 patients with closed head injuries (8%) in the series, 2 of the 23 with C-spine injuries (9%), 33 of the 112 with chest injuries (29%), and 12 of the 86 with abdominal injuries (14%). In 19 patients, none of the four CT scans was supported; nine of these had an injury identified, and six were admitted to the hospital (1 to the intensive care unit). Injuries that would have been missed included intraventricular and intracerebral hemorrhage (4), subarachnoid hemorrhage (2), cerebral contusion (1), C1 fracture (1), spinous and transverse process fractures (3), vertebral fracture (6), lung lacerations (1), lung contusions (14), small pneumothoraces (7), grade II-III liver and splenic lacerations (6), and perinephric or mesenteric hematomas (2). CONCLUSIONS In this small sample, physicians were willing to omit 27% of scans. If this was done, two injuries requiring immediate actions would have been missed initially, and other potentially important injuries would have been missed in 17% of patients.

Principles of appropriate antibiotic use for acute pharyngitis in adults : Background

The following principles of appropriate antibiotic use for adults with acute pharyngitis apply to immunocompetent adults without complicated comorbid conditions, such as chronic lung or heart disease, and history of rheumatic fever. They do not apply during known outbreaks of group A streptococcus.1. Group A beta-hemolytic streptococcus (GABHS) is the causal agent in approximately 10% of adult cases of pharyngitis. The large majority of adults with acute pharyngitis have a self-limited illness, for which supportive care only is needed.2. Antibiotic treatment of adult pharyngitis benefits only those patients with GABHS infection. All patients with pharyngitis should be offered appropriate doses of analgesics and antipyretics, as well as other supportive care.3. Limit antibiotic prescriptions to patients who are most likely to have GABHS infection. Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria: history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy (lymphadenitis). Do not test or treat patients with none or only one of these criteria, since these patients are unlikely to have GABHS infection. For patients with two or more criteria the following strategies are appropriate: a) Test patients with two, three, or four criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results; b) test patients with two or three criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results or patients with four criteria; or c) do not use any diagnostic tests, and limit antibiotic therapy to patients with three or four criteria. 4. Throat cultures are not recommended for the routine primary evaluation of adults with pharyngitis or for confirmation of negative results on rapid antigen tests when the test sensitivity exceeds 80%. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for monitoring the development and spread of antibiotic resistance, or when such pathogens as gonococcus are being considered.5. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin in a penicillin-allergic patient.

Interrater reliability of cervical spine injury criteria in patients with blunt trauma.

STUDY OBJECTIVE To determine the interrater reliability of previously defined risk criteria for cervical spine injury. METHODS Two emergency physicians independently evaluated patients with blunt trauma to determine whether they exhibited any of four risk criteria: (1) altered neurologic function; (2) evidence of intoxication; (3) spinous process or posterior midline cervical tenderness; or (4) distracting painful injury. Each criterion was explicitly described on study data forms. Physician concordance was measured, and the kappa statistic was calculated, for the combined risk criteria (based on the presence of any individual criterion), and for each individual criterion. RESULTS There were 122 patients evaluated. Physicians agreed on overall classifications for 107 patients (87.7%; kappa, .73; confidence interval [CI], .61 to .86). Agreement for individual criteria were as follows: (1) altered neurologic function--102 patients (83.6%; kappa, .58; CI, .41 to .74); (2) intoxication--118 patients (96.7%; kappa, .86; CI, .72 to .99); (3) posterior midline tenderness--109 patients (89.3%; kappa, .77; CI .65 to .89); (4) distracting injury--112 patients (91.8%; kappa.77; CI, .64 to .91). CONCLUSION The combined cervical spine injury criteria have substantial interrater reliability. Individual criteria are slightly less reliable.

Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: Background

Abstract The following principles of appropriate antibiotic use for adults with acute bronchitis apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease. 1. The evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out serious illness, particularly pneumonia. In healthy, nonelderly adults, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds, and chest radiography is usually not indicated. In patients with cough lasting 3 weeks or longer, chest radiography may be warranted in the absence of other known causes. 2. Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. If pertussis infection is suspected (an unusual circumstance), a diagnostic test should be performed and antimicrobial therapy initiated. 3. Patient satisfaction with care for acute bronchitis depends most on physician–patient communication rather than on antibiotic treatment. [Gonzales R, Bartlett JG, Besser RE, Cooper RJ, Hickner JM, Hoffman JR, Sande MA. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Emerg Med. June 2001;37:720-727.]

Effect of Cardiologist ECG Review on Emergency Department Practice

STUDY OBJECTIVE To determine the effect of cardiology review of ECGs on emergency department practice. METHODS We carried out a prospective cohort study at an urban teaching ED. Our subjects were adult patients undergoing electrocardiography. We prospectively collected 1,000 consecutive ECGs and classified them by severity according to the following system: class 1, normal or minor abnormalities only; class 2, abnormalities with potential to alter case management; and class 3, potentially life-threatening abnormalities. Actual ECG readings by ED physicians (who had access to computerized interpretations at the time of treatment) were compared with those of staff cardiology quality-assurance reviewers; if they were not in agreement, an expert cardiology panel blindly chose the superior interpretation. Subsequently, an expert emergency physician panel reviewed discordant readings for discharged patients to determine the need for further action. RESULTS Of 1,000 ECGs, the readings for 190 (19%) were significantly discordant. The expert cardiology panel preferred the ED reading in 72 cases (38%) and the staff cardiology reading in 118 (62%). In 30 other cases no ED reading was recorded in the medical record. Of the 148 cases in which the expert cardiology panel agreed with the cardiology reading or there was no ED reading, 102 patients were admitted and 46 discharged. Of the 46 discharges, 8 cardiology readings were categorized as class 1, leaving only 38 cases in which the staff cardiology reading might have affected the ED decision to discharge a patient. All of these readings were in class 2, with the exception of one unclassifiable diagnosis. There were no class 3 readings. On expert emergency physician panel review of these 38 ECGs and interpretations, only 8 (.8%, 95% confidence interval, .3% to 1.6%) were considered sufficiently important to warrant chart review. In actual practice, none of these cases was affected by the ECG quality-assurance (QA) process. Two of these patients died during our 1-year follow-up. In one of these cases, the ECG QA process could have altered the patients outcome. CONCLUSION The existing ECG review process as mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will likely have minimal influence on patient outcomes at our institution. We should establish the effectiveness of this mandated QA process before committing scarce resources to its performance.