Vincenza Snow

Risk Assessment for and Strategies To Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery: A Guideline from the American College of Physicians

Recommendations Recommendation 1: All patients undergoing noncardiothoracic surgery should be evaluated for the presence of the following significant risk factors for postoperative pulmonary complications in order to receive pre- and postoperative interventions to reduce pulmonary risk: chronic obstructive pulmonary disease, age older than 60 years, American Society of Anesthesiologists (ASA) class of II or greater, functionally dependent, and congestive heart failure. The following are not significant risk factors for postoperative pulmonary complications: obesity and mild or moderate asthma. Recommendation 2: Patients undergoing the following procedures are at higher risk for postoperative pulmonary complications and should be evaluated for other concomitant risk factors and receive pre- and postoperative interventions to reduce pulmonary complications: prolonged surgery (>3 hours), abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, aortic aneurysm repair, emergency surgery, and general anesthesia. Recommendation 3: A low serum albumin level (<35 g/L) is a powerful marker of increased risk for postoperative pulmonary complications and should be measured in all patients who are clinically suspected of having hypoalbuminemia; measurement should be considered in patients with 1 or more risk factors for perioperative pulmonary complications. Recommendation 4: All patients who after preoperative evaluation are found to be at higher risk for postoperative pulmonary complications should receive the following postoperative procedures in order to reduce postoperative pulmonary complications: 1) deep breathing exercises or incentive spirometry and 2) selective use of a nasogastric tube (as needed for postoperative nausea or vomiting, inability to tolerate oral intake, or symptomatic abdominal distention). Recommendation 5: Preoperative spirometry and chest radiography should not be used routinely for predicting risk for postoperative pulmonary complications. Preoperative pulmonary function testing or chest radiography may be appropriate in patients with a previous diagnosis of chronic obstructive pulmonary disease or asthma. Recommendation 6: The following procedures should not be used solely for reducing postoperative pulmonary complication risk: 1) right-heart catheterization and 2) total parenteral nutrition or total enteral nutrition (for patients who are malnourished or have low serum albumin levels). Introduction Postoperative pulmonary complications play a significant role in the risk for surgery and anesthesia. The most important and morbid postoperative pulmonary complications are atelectasis, pneumonia, respiratory failure, and exacerbation of underlying chronic lung disease. While clinicians are very conscious of the importance of, and risk factors for, cardiac complications, clinicians who care for patients in the perioperative period may be surprised to learn that postoperative pulmonary complications are equally prevalent and contribute similarly to morbidity, mortality, and length of stay (1-5). Pulmonary complications may also be more likely than cardiac complications to predict long-term mortality after surgery, particularly among older patients (6). This guideline is based on a 2-part systematic review prepared by Smetana and colleagues (7) and Lawrence and colleagues (8). The American College of Physicians (ACP) developed these guidelines to 1) guide clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery and 2) evaluate the efficacy of strategies to reduce the risk for postoperative pulmonary complications. Studies of immunosuppressive states other than HIV infection (for example, organ transplantation) and of risk factors for postoperative venous thromboembolism were excluded from the review. The target audience is general internists or other clinicians involved in perioperative management of surgical patients. This guideline applies to adult patients undergoing noncardiopulmonary surgery. The perioperative period as defined in the studies ranged from 2 to 3 months before surgery and up to 3 months after surgery. A more in-depth discussion of the methods and the inclusion and exclusion criteria is available in the accompanying background papers in this issue (7, 8). In this paper, patient- and procedure-related risk factors are discussed separately. Patient-Related Risk Factors Potential patient-related risk factors fell into the following general categories: age; chronic lung disease; cigarette use; congestive heart failure; functional dependence; American Society of Anesthesiologists (ASA) classification; obesity; asthma; obstructive sleep apnea; impaired sensorium, abnormal findings on chest examination, alcohol use, and weight loss; and exercise capacity, diabetes, and HIV infection. Age The evidence review found that advanced age is an important predictor of postoperative pulmonary complications, even after adjustment for comorbid conditions. Ten multivariable studies showed that age was a significant risk predictor and was the second most commonly identified risk factor. The odds ratio was 2.09 (95% CI, 1.70 to 2.58) for patients 60 to 69 years of age and 3.04 (CI, 2.11 to 4.39) for those 70 to 79 years of age compared with younger patients (those <60 years of age). Chronic Lung Disease Among studies reporting multivariable analyses, chronic obstructive pulmonary disease was the most commonly identified risk factor for postoperative pulmonary complications (odds ratio, 1.79 [CI, 1.44 to 2.22]). No eligible study determined the incremental risk for postoperative pulmonary complications in patients with chronic restrictive lung disease or restrictive physiologic characteristics due to neuromuscular disease or chest wall deformity, such as kyphoscoliosis. While clinicians may consider such patients with severe limitations to have an increased risk for postoperative pulmonary complications, the literature did not support an estimate of the magnitude of this risk in this group. Cigarette Use The available data are mixed but suggest a modest increase in risk for postoperative pulmonary complications among current smokers. The odds ratio for cigarette use was 1.26 (CI, 1.01 to 1.56). It is important to assess history of current smoking status and support for smoking cessation intervention very early in the preparation for nonemergency surgery. Congestive Heart Failure Good-quality evidence identified congestive heart failure as a significant risk factor for postoperative pulmonary complications (odds ratio, 2.93 [CI, 1.02 to 8.43]). Functional Dependence The evidence review showed that functional dependence is an important predictor of postoperative pulmonary complications. Total dependence was the inability to perform any activities of daily living, and partial dependence was the need for equipment or devices and assistance from another person for some activities of daily living. The odds ratio was 2.51 (CI, 1.99 to 3.15) for total dependence and 1.65 (CI, 1.36 to 2.01) for partial dependence. ASA Classification Several integrated measures of comorbidity have been evaluated as potential predictors of postoperative pulmonary complications. The ASA classification (Table) aims to predict perioperative mortality rates but has since been proven to predict both postoperative pulmonary and cardiac complications (9). Higher ASA class was associated with a substantial increase in risk when an ASA class of II or greater was compared with an ASA class of less than II (odds ratio, 4.87 [CI, 3.34 to 7.10]) and when an ASA class of III or greater was compared with an ASA class of less than III (odds ratio, 2.25 [CI, 1.73 to 3.76]). Table. American Society of Anesthesiologists Classification Obesity Studies evaluating clinically meaningful pulmonary complications after surgery have generally found no increased risk attributable to obesity, even for patients with morbid obesity (10, 11). Definitions of obesity varied from a body mass index of more than 25 kg/m2 to morbid obesity. Postoperative pulmonary complication rates were 6.3% and 7.0% for obese and nonobese patients, respectively, in studies that reported only univariate data. Asthma Good evidence suggested that asthma is not a risk factor for postoperative pulmonary complications. Only 1 of 4 studies that examined the rate of postoperative pulmonary complications among patients with asthma included a control group; the rate in this study was 3%. Obstructive Sleep Apnea Obstructive sleep apnea increases the risk for airway management difficulties in the immediate postoperative period, but its influence on postoperative pulmonary complications has not been well studied. The evidence review identified a single univariate study that evaluated the risk due to obstructive sleep apnea among patients undergoing hip or knee replacement (12). In this casecontrol study, nonsignificant trends were seen toward higher rates of reintubation, hypercapnia, and hypoxemia for patients with obstructive sleep apnea. This finding suggests that postoperative pulmonary complication rates may have been higher among patients with obstructive sleep apnea, but this needs to be confirmed by more studies. Impaired Sensorium, Abnormal Findings on Chest Examination, Alcohol Use, and Weight Loss Fair evidence shows that impaired sensorium, abnormal findings on chest examination, alcohol use, and weight loss modestly increase the risk for postoperative pulmonary complications. Impaired sensorium is defined as 1) an acutely confused or delirious patient who is able to respond to verbal stimulation, mild tactile stimulation, or both, or 2) a patient with mental status changes, delirium, or both in the context of current illness. This definition excludes patients with stable chronic mental illness or dementia. Exercise Capacity, Diabetes, and HIV Infection Evidence was insufficient to support w

Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians.

DESCRIPTION The American College of Physicians (ACP) developed this guideline to present the evidence for the link between the use of intensive insulin therapy to achieve different glycemic targets and health outcomes in hospitalized patients with or without diabetes mellitus. METHODS Published literature on this topic was identified by using MEDLINE and the Cochrane Library. Additional articles were obtained from systematic reviews and the reference lists of pertinent studies, reviews, and editorials, as well as by consulting experts; unpublished studies on ClinicalTrials.gov were also identified. The literature search included studies published from 1950 through March 2009. Searches were limited to English-language publications. The primary outcomes of interest were short-term mortality and hypoglycemia. This guideline grades the evidence and recommendations by using the ACP clinical practice guidelines grading system. RECOMMENDATION 1: ACP recommends not using intensive insulin therapy to strictly control blood glucose in non-surgical intensive care unit (SICU)/medical intensive care unit (MICU) patients with or without diabetes mellitus (Grade: strong recommendation, moderate-quality evidence). RECOMMENDATION 2: ACP recommends not using intensive insulin therapy to normalize blood glucose in SICU/MICU patients with or without diabetes mellitus (Grade: strong recommendation, high-quality evidence). RECOMMENDATION 3: ACP recommends a target blood glucose level of 7.8 to 11.1 mmol/L (140 to 200 mg/dL) if insulin therapy is used in SICU/MICU patients (Grade: weak recommendation, moderate-quality evidence).

Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine

The American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions. Over 30 organizations sent representatives to the Transitions of Care Consensus Conference. Participating organizations included medical specialty societies from internal medicine as well as family medicine and pediatrics, governmental agencies such as the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services, performance measure developers such as the National Committee for Quality Assurance and the American Medical Association Physician Consortium on Performance Improvement, nurse associations such as the Visiting Nurse Associations of America and Home Care and Hospice, pharmacist groups, and patient groups such as the Institute for Family-Centered Care. The Transitions of Care Consensus Conference made recommendations for standards concerning the transitions between inpatient and outpatient settings for future implementation. The American College of Physicians, Society of Hospital Medicine, Society of General Internal Medicine, American Geriatric Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine all endorsed this document.

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

Pharmacologic Management of Acute Attacks of Migraine and Prevention of Migraine Headache

Migraine headache is a common disorder seen in primary care. It affects 18% of women and 6.5% of men in the United States, almost half of whom are undiagnosed or undertreated (1, 2). These guidelines, developed by the American Academy of Family Physicians and the American College of PhysiciansAmerican Society of Internal Medicine, with assistance from the American Headache Society, are based on two previously published papers (3, 4). The papers, titled Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management of Acute Attacks, by Matchar and colleagues (3), and Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management for Prevention of Migraine, by Ramadan and coworkers (4), can be found at www.aan.com/professionals/practice/guidelines.cfm.1 The target audience for this guideline is primary care physicians. The guideline applies to patients with acute migraine attacks, with or without aura, and patients with migraine who are candidates for preventive drug therapy. Although these guidelines are all based on the articles by Matchar and Ramadan and colleagues, the recommendations may differ because different thresholds of evidence were needed for making a positive recommendation. Table 1 compares the AAFP/ACPASIM guideline and the U.S. Headache Consortium Guideline. Table 1. Summary of U.S. Headache Consortium Recommendations Compared with AAFP/ACPASIM Recommendations Throughout the text, asterisks indicate drugs that are currently not available in the United States. Diagnosis Headache has many potential causes. Most headaches are caused by the primary headache disorders, which include migraine, cluster, and tension-type headaches. Secondary headaches, which are those with underlying pathologic causes, are far less common. Migraine is a chronic condition with recurrent acute attacks whose characteristics vary among patients and often among attacks within a single patient. Migraine is a syndrome with a wide variety of neurologic and non-neurologic manifestations. The International Headache Society (6) has developed diagnostic criteria for migraine with and without aura (Appendix Table 1). This classification system serves to diagnose headache syndromes, not patients. Thus, one patient could have more than one type of headache disorder. For example, it is not uncommon for migraine patients to also have episodic tension-type headaches. Management of Acute Attacks Effective long-term management of patients with migraine is challenging because of the complexity of the condition. Experts suggest several goals for successful treatment of acute attacks of migraine. These include treating attacks rapidly and consistently to avoid headache recurrence, to restore the patients ability to function, and to minimize the use of backup and rescue medications. Clinicians need to educate people with migraine about their condition and its treatment and encourage them to participate in their own management. The physician must help the patient establish realistic expectations by discussing therapeutic options and their benefits and harms. Patient input can provide the best guide to treatment selection and helps the physician to better understand and accommodate patient treatment goals. Developing an effective acute migraine management strategy can be complex, and an engaged patient is more likely to negotiate this process successfully. Encouraging patients to identify and avoid triggers (Table 2) and to be actively involved in their own management by tracking their own progress may be especially useful. Table 2. Some Commonly Reported Triggers of Migraine Headache Once a diagnosis of migraine is established, patients and their health care providers should decide together how to treat acute attacks and whether the patient is a candidate for preventive medications. A wide range of acute treatments with varying efficacies is currently in use (Appendix Table 2). A comprehensive review of the scientific literature, especially the data from randomized, controlled trials, provides a list of treatments that have demonstrated efficacy in the management of acute migraine headache. It also provides a clear understanding of the adverse events associated with various agents. The Headache Consortiums review of the evidence on antiemetics, barbiturate hypnotics, ergot alkaloids and derivatives, nonsteroidal anti-inflammatory drugs (NSAIDs), combination analgesics and nonopiate analgesics, opiate analgesics, triptans, and other agents found good evidence of the efficacy of only a few agents in the treatment of acute migraine (3). Available Agents NSAIDs Their demonstrated efficacy and favorable tolerability make NSAIDs a first-line treatment choice for all migraine attacks, including severe attacks that have responded to NSAIDs in the past. Among the NSAIDs, the most consistent evidence exists for aspirin (8-10), ibuprofen (11, 12), naproxen sodium (13, 14), tolfenamic acid* (8, 15), and the combination agent acetaminophen plus aspirin plus caffeine for the acute treatment of migraine (16). The evidence shows that acetaminophen alone is ineffective (17). Serotonin1B/1D Agonists (Triptans) There is good evidence for the effectiveness of the oral triptans naratriptan (18, 19), rizatriptan (20-23), sumatriptan (24-31), and zolmitriptan (32-34). In addition, there is good evidence for the effectiveness of subcutaneous (35-38) and intranasal (39-41) sumatriptan, making it an option for patients with nausea and vomiting. Adverse effects of the triptans include chest symptoms, but postmarketing data indicate that true ischemic events are rare. Triptans are contraindicated in patients with risk for heart disease, basilar or hemiplegic migraine, or uncontrolled hypertension. Subcutaneous sumatriptan is associated with a very rapid onset of action, and oral naratriptan is associated with a slower onset of action. Ergotamines There is good evidence for the efficacy and safety of intranasal dihydroergotamine (DHE) as monotherapy for acute migraine attacks (42-46). Placebo-controlled studies of intravenous DHE did not clearly establish its efficacy in the acute treatment of migraine (47, 48). The evidence was inconsistent to support efficacy of ergotamine or ergotaminecaffeine, and the studies documented frequent adverse events. Opioids It is well recognized that opiates are good analgesics, but there is good evidence only for the efficacy of butorphanol nasal spray (49, 50). Although opioids are commonly used, surprisingly few studies of opioid use in headache pain document whether overuse and the development of dependence are as frequent as clinically perceived. Until further data are available, these drugs may be better reserved for use when other medications cannot be used, when sedation effects are not a concern, or the risk for abuse has been addressed. Other Agents Fair evidence suggests that the antiemetic metoclopramide, given intravenously, may be an appropriate choice as monotherapy for acute attacks (51-53), particularly in patients with nausea and vomiting when the sedating side effect may also be useful. Isometheptene and isometheptene combinations obtained only borderline significance in relieving headache pain (17, 54, 55). Other agents used in practice, such as intravenous corticosteroids and intranasal lidocaine, are not effective. Choice of Treatment Since patient responses to these therapies are not always predictable, individualized management is important. The choice of treatment should be based on, among other characteristics, the frequency and severity of attacks; the presence and degree of temporary disability; and the profile of associated symptoms, such as nausea and vomiting. The patients history of, response to, and tolerance for specific medications must also be considered. Coexisting conditions (such as heart disease, pregnancy, and uncontrolled hypertension) may limit treatment choices. No studies document the effectiveness of specific treatment schedules, but experts suggest that acute therapy should be limited to no more than two times per week to guard against medication-overuse headache (or drug-induced headache). Medication-overuse headache is thought to result from frequent use of acute medication and has a pattern of increasing headache frequency, often resulting in daily headaches. In patients with suspected medication overuse or patients at risk for medication overuse, preventive migraine therapy should be considered. Although some use the term rebound headache interchangeably with the term medication-overuse headache, rebound headache is a distinct entity. Rebound headache is associated with withdrawal of analgesics or abortive migraine medication. There is no uniform agreement about which agents can cause rebound headache, although ergotamine (not DHE); opiates; triptans; and simple and mixed analgesics containing butalbital, caffeine, or isometheptene are generally thought to do so. There is less uniform opinion about other antimigraine agents. Another clinical consideration is the use of a self-administered rescue medication for patients with severe migraine attack that is not responding to (or failing) other treatments. A rescue medication is an agent such as an opioid or a butalbital-containing compound that the patient can use at home when other treatments have failed. Although rescue medications often do not completely eliminate pain and allow patients to return to normal activities, they permit the patient to achieve relief without the discomfort and expense of a visit to the physicians office or emergency department. A cooperative arrangement between provider and patient may extend to the use of rescue medication in appropriate situations. Summary of Treatment of Acute Migraine A body of evidence now points to effective first- and second-line agents for acute treatment of migraine. Beyond the choice of agent lies the

Evidence Base for Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease

The American College of PhysiciansAmerican Society of Internal Medicine (ACPASIM) and the American College of Chest Physicians (ACCP) developed this evidence-based clinical practice guideline in collaboration. A joint expert panel examined the evidence and developed recommendations. The numbers in square brackets are cross-references to the numbered sections in the accompanying background paper, Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Summary and Appraisal of Published Evidence, which is part 2 of this guideline (see pages 600-620). The guideline and background paper are based primarily on a systematic review compiled in an Agency for Healthcare Research and Policy evidence report prepared by the Evidence-Based Practice Center at Duke University (1). Our target audience is primary care physicians and specialists who care for patients with chronic obstructive pulmonary disease (COPD). Although most acute exacerbations of COPD take place and are treated on an outpatient basis, research studies focus on emergency department or inpatient settings. As a result, this guideline applies to exacerbations treated in those settings. The guideline presents the available evidence on risk stratification for relapse and 6-month mortality rates, diagnostic testing for acute exacerbations of COPD, and current treatment options for acute exacerbations of COPD. In the United States, 16 million adults have COPD, which accounts annually for 110 000 deaths, more than 16 million office visits, 500 000 hospitalizations, and

The Development of Clinical Practice Guidelines and Guidance Statements of the American College of Physicians: Summary of Methods

18 billion in direct health care costs. The disease is characterized by chronic airflow obstruction and episodic increases in dyspnea, cough, and sputum production that are commonly called exacerbations. After an acute exacerbation, most patients experience a transitory or permanent decrease in quality of life, and nearly 50% of patients discharged from hospitals after acute exacerbations are readmitted more than once in the following 6 months. Therefore, one of the main treatment goals for patients with COPD is reducing the number and severity of annual exacerbations. There is no widely accepted definition of acute exacerbation of COPD, but most published definitions encompass some combination of three clinical findings: worsening dyspnea, increase in sputum purulence, and increase in sputum volume. A severity scale for acute exacerbations developed by Anthonisen and colleagues (2) is based on these findings as well as others. Type 1 exacerbations (severe) have all three clinical findings, and type 2 exacerbations (moderate) exhibit two. Type 3 exacerbations (mild) have one of these clinical findings plus at least one of the following: an upper respiratory tract infection in the past 5 days, fever without other apparent cause, increased wheezing, increased cough, or a 20% increase in respiratory rate or heart rate above baseline. We use this scale when referring to severity in this guideline. Acute exacerbations can be triggered by tracheobronchial infections or environmental exposures, and patients often have associated clinical conditions, such as heart failure, extrapulmonary infections, and pulmonary embolism. Therefore, acute exacerbation is mainly a clinical diagnosis. Despite the importance of this disease, the review of the evidence brings to light the paucity of high-quality studies on this subject. Nevertheless, recommendations in this guideline are based on the highest-quality evidence currently available. While the studies of highest quality were often randomized, controlled clinical trials, these were few in number and tended to enroll small numbers of patients. The clinician must consider this fact when basing management decisions on the guideline recommendations. Current practices for the diagnosis and management of acute exacerbations of COPD are varied. Some commonly used tests and therapies are not supported by evidence, while others are. The Panel found enough evidence to make recommendations about the use of the following diagnostic and therapeutic methods in acute exacerbations of COPD: chest radiography, acute spirometry, bronchodilators, corticosteroids, antibiotics, oxygen, mucolytic agents, mucus-clearing strategies, and noninvasive positive-pressure ventilation (NPPV). Indirect evidence shows that arterial blood gases are helpful for determining the present need for oxygen therapy and the potential need for mechanical ventilatory support. We did not find enough evidence to make recommendations regarding the use of pulse oximetry, sputum smear, and culture. Risk Stratification Prediction of Outpatient Relapse All of the studies included for analysis were performed in the emergency department. Relapse was defined as a return visit to the emergency department within 14 days of initial presentation. Identifying patients at high risk for relapse should help guide decisions about hospital admission and follow-up appointments. Several studies have confirmed what most clinicians intuitively know: Patients who have lower baseline FEV1, low Po 2, high Pco 2, and low pH and who receive more bronchodilator treatments while in the emergency department are more likely to relapse within 14 days of initial presentation. Unfortunately, none of the predictive models perform well enough to justify their uniform use in clinical practice [2.1.1]. Prediction of 6-Month Mortality The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) found a 180-day mortality rate of 33% in its cohort. Significant predictors of 180-day mortality were worse Acute Physiology and Chronic Health Evaluation (APACHE) III score, lower body mass index, older age, worse functional status 2 weeks before admission, lower ratio of Po 2 to fraction of inspired oxygen, history of congestive heart failure, lower serum albumin level, and presence of cor pulmonale. Other studies reported similar associations. Although these studies suggest that certain physiologic characteristics are associated with a higher likelihood of inpatient mortality, we conclude that there is currently no reliable method for identifying patients at high risk (>90%) for inpatient or 6-month mortality. Therefore, these measures should not influence decisions about instituting, continuing, or withdrawing life-sustaining therapies but should prompt a discussion regarding patient preferences for end-of-life care [2.1.2]. Diagnostic Testing: Chest Radiography and Spirometry Three observational studies showed substantial rates of abnormalities in chest radiography among patients admitted for acute exacerbation of COPD. In one prospective study, which included patients with asthma, chest radiography results prompted change in management in 23.5% of patients, mostly because of new infiltrates. Observational studies showed that spirometric assessment at presentation or during treatment is not useful in judging severity or guiding management of patients with acute exacerbations of COPD. When measured at the time of an exacerbation, FEV1 showed no significant correlation with Po 2 and only a weak (although statistically significant) correlation with Pco 2. Peak expiratory flow rate is often used in the clinic to approximate FEV1. One study found a correlation between peak expiratory flow rate and FEV1. The clinical implication of this finding is not clear, however, because FEV1 is a poor predictor. Despite this fact, many studies use changes in FEV1 as the primary outcome rather than other, more clinically pertinent measures (such as degree of dyspnea or sputum production and quality), probably because the latter are much more difficult to quantify and evaluate [2.2.2, 2.2.3]. Therapeutic Interventions Bronchodilators Fourteen randomized trials show that inhaled short-acting 2 agonists, such as albuterol, and anticholinergic bronchodilators, such as ipratropium, are equally efficacious in patients with acute exacerbations of COPD. They are also superior to all parenterally administered bronchodilators, including methylxanthines and sympathomimetic agents. Furthermore, some patients may experience additional benefit when a second inhaled bronchodilating agent is administered after the maximal dose of the initial agent is reached. Several studies examined patients receiving a short-acting 2 agonist plus an anticholinergic bronchodilator. In general, patients in these studies had marginally shorter lengths of stay and proportionally larger increases in FEV1, but hospital admission rates were similar to those of patients receiving one bronchodilator. Since anticholinergic bronchodilators are associated with fewer and milder side effects, it is advisable to start with them and then add a short-acting 2 agonist. Studies are equivocal on the addition of a methylxanthine, such as aminophylline, to inhaled bronchodilators. More important, the potentially serious side effects of the methylxanthines make their use more problematic. In addition, some evidence shows that the efficacy of wet nebulization and dry aerosol delivery systems (metered-dose inhaler plus a spacer) are clinically equivalent. Therefore, the choice of a specific delivery method should be determined on an individual basis, depending on each patients ability to use the different methods (3) [2.3.1]. Corticosteroids Six randomized, placebo-controlled trials showed that for patients hospitalized with acute exacerbation of COPD, systemic corticosteroids given for up to 2 weeks are helpful. Dosage, length of treatment, administration, and setting varied greatly among the studies evaluated. In the largest trial (Systemic Corticosteroids in Chronic Obstructive Pulmonary Disease Exacerbations), patients received a 2-week or 8-week course. The 2-week course consisted of 3 days of intravenous methylprednisolone, 125 mg every 6 hours, followed by oral prednisone for 2 weeks (60 mg/d on days 4 to 7, 40 mg/d on days 8 to 11, and 20 mg/d on days 12 to 15

Lipid Control in the Management of Type 2 Diabetes Mellitus: A Clinical Practice Guideline from the American College of Physicians

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACPs Guidelines Committee and the staff of the Clinical Programs and Quality of Care Department develop the clinical recommendations. The ACP develops 2 different types of clinical recommendations: clinical practice guidelines and clinical guidance statements. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading. All ACP clinical practice guidelines and clinical guidance statements, if not updated, are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

Principles of appropriate antibiotic use for acute sinusitis in adults.

Diabetes mellitus is a leading cause of morbidity and mortality in the United States. Type 2 diabetes mellitus is most common (90% to 95% of persons with diabetes) and affects older adults, particularly those older than 50 years of age. An estimated 16 million Americans have type 2 diabetes, and up to 800000 new diagnoses are made each year (1, 2). Most adverse diabetes outcomes are a result of vascular complications, which are generally classified as microvascular (such as retinopathy, nephropathy, and neuropathy, although the latter may not be entirely a microvascular disease) or macrovascular (such as coronary artery disease, cerebrovascular disease, and peripheral vascular disease). To prevent or diminish the progression of microvascular and macrovascular complications, recommended diabetes management necessarily encompasses both metabolic control and control of cardiovascular risk factors (3-5). The need for good glycemic control is supported by the Diabetes Control and Complications Trial (6) in type 1 diabetes and, more recently, the United Kingdom Prospective Diabetes Study in type 2 diabetes (7). In these studies, tight blood sugar control reduced microvascular complications such as nephropathy and retinopathy but had little effect on macrovascular outcomes. Up to 80% of patients with type 2 diabetes will develop or die of macrovascular disease, underscoring the importance of preventing macrovascular complications. In an effort to provide internists and other primary care physicians with effective management strategies for diabetes care, the American College of Physicians (ACP) decided to develop guidelines on the management of dyslipidemia, particularly hypercholesterolemia, in people with type 2 diabetes. A previous College guideline addressed the critical role of tight blood pressure control in type 2 diabetes mellitus (8, 9). The target audience for this guideline is all clinicians who care for patients with type 2 diabetes. The target patient population is all persons with type 2 diabetes, including those who already have some form of microvascular complication and, of particular importance, premenopausal women. In this guideline we address the following questions. 1. What are the benefits of tight lipid control for both primary and secondary prevention in type 2 diabetes? 2. What is the evidence for treating to certain target levels of low-density lipoprotein (LDL) cholesterol for patients with type 2 diabetes? 3. Are certain lipid-lowering agents more effective or beneficial in patients with type 2 diabetes? This guideline is based on the systematic review of the evidence presented in the background paper by Vijan and colleagues in this issue (10). When Vijan and colleagues analyzed benefit or effectiveness, only studies that measured clinical end points were included. The major clinical end points in trials used to support the evidence for these guidelines were all-cause mortality, cardiovascular mortality, and cardiovascular events (that is, myocardial infarction, stroke, and cardiovascular mortality). No studies of lipid-lowering therapy have been conducted solely in patients with diabetes. Moreover, many trials excluded patients with diabetes. The sample sizes of participants with diabetes were often small, and many studies reported results only for the combined groups. Thus, the reports included in this review are of the subgroup analyses for studies that included patients with diabetes. The review was stratified into 2 categories. The first category evaluated the effects of lipid management in primary prevention (that is, in patients without known coronary disease). The second category evaluated the effects in secondary prevention (that is, in patients with established coronary disease). A total of 12 lipid-lowering studies presented diabetes-specific data and reported clinical outcomes. A discussion of this evidence follows (for a more detailed description of methodology, refer to the background paper by Vijan and colleagues [10]). Primary Prevention Six studies of primary prevention in patients with diabetes were identified. The Air Force Coronary Atherosclerosis Prevention Study/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS) randomly assigned patients with average cholesterol levels and lower than average high-density lipoprotein (HDL) cholesterol levels to lovastatin, 20 to 40 mg/d, or placebo (in addition to a low-fat and low-cholesterol diet) for an average follow-up of 5.2 years (11). Based on data from the Third National Health and Nutrition Examination Survey, mean total cholesterol level was 5.72 mmol/L (221 mg/dL), mean LDL cholesterol level was 3.88 mmol/L (150 mg/dL), and mean HDL cholesterol level was 0.93 mmol/L (36 mg/dL) for men and 1.03 mmol/L (40 mg/dL) for women. One hundred fifty-five patients had diabetes. Lovastatin therapy led to a relative risk of 0.56 (95% CI, 0.17 to 1.92) for any atherosclerotic cardiovascular event (first fatal or nonfatal myocardial infarction, unstable angina, or sudden cardiac death) and an absolute risk reduction of 0.04 (CI, 0.04 to 0.12), neither of which was statistically significant. The mean LDL cholesterol level at the end of the study was 2.97 mmol/L (115 mg/dL), and the mean HDL cholesterol level was 1.00 mmol/L (39 mg/dL). The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial-Lipid-Lowering Trial (ALLHAT-LLT) randomly assigned patients 55 years of age and older who had hypertension and at least one other coronary heart disease (CHD) risk factor to pravastatin, 40 mg/d, or placebo (12). In the subgroup analysis of 3638 patients with type 2 diabetes, the relative risk for CHD events was 0.89 (CI, 0.71 to 1.10); the absolute risk reduction was not reported. This study has been criticized because of the smaller difference between LDL cholesterol levels in the control and intervention groups, which is probably due in part to contamination of the control group by publication of several other lipid-lowering trials during the study. The Helsinki Heart Study (13) randomly assigned men age 40 to 55 years with elevated non-HDL cholesterol levels to gemfibrozil, 600 mg 2 times per day, or placebo. The mean total cholesterol level was 7.5 mmol/L (290 mg/dL), and mean HDL cholesterol level was 1.23 mmol/L (47.6 mg/dL). In the 135 patients with diabetes, the incidence of CHD at 5 years was 3.4% in the gemfibrozil group and 10.5% in the placebo group. The relative risk was 0.32 (CI, 0.07 to 1.46), and the absolute risk reduction was 0.07 (CI, 0.01 to 0.15). None of these differences were statistically significant (14). The Heart Protection Study (HPS) included data on both primary and secondary prevention in patients with diabetes who were at high risk for cardiovascular disease (15). The objective of this study was to examine the effects of therapy to lower LDL cholesterol level across a broad range of lipid levels and risk factors. The HPS enrolled patients 40 to 80 years of age with nonfasting total cholesterol levels of at least 3.49 mmol/L ( 135 mg/dL). In the primary prevention group, 3982 patients had diabetes. Treatment with simvastatin, 40 mg, led to reduced risks for CHD events (relative risk, 0.74 [CI, 0.64 to 0.85]; absolute risk reduction, 0.05 [CI, 0.03 to 0.07]). The Prospective Study of Pravastatin in the Elderly at Risk (PROSPER) randomly assigned men and women 70 to 82 years of age with a history of cerebral or peripheral vascular disease or risk factors for such disease (such as smoking, hypertension, and diabetes) to pravastatin, 40 mg/d, or placebo (16). In the primary prevention group, 396 patients had diabetes. In these patients, treatment with pravastatin led to a trend toward harm (relative risk, 1.23 [CI, 0.77 to 1.95]; absolute risk reduction, 0.03 [CI, 0.10 to 0.04]). The interaction between diabetes and the treatment group was statistically significant, suggesting that patients with diabetes did substantially worse than those without diabetes. The Anglo-Scandinavian Cardiac Outcome Trial-Lipid Lowering Arm (ASCOT-LLA) randomly assigned patients age 40 to 79 years without CHD but with hypertension and at least 3 other cardiovascular risk factors (left ventricular hypertrophy, other electrocardiographic abnormalities, type 2 diabetes, peripheral arterial disease, previous stroke or transient ischemic attack, male sex, age 55 years, microalbuminuria, proteinuria, smoking, ratio of plasma total to HDL cholesterol of 6 or higher, or family history of premature CHD) to atorvastatin, 10 mg/d, or placebo (17). The diabetes subgroup, 2532 patients who had hypertension and at least 2 other risk factors, had low event rates of 3.6% in the control group and 3.0% in the intervention group. Thus, lipid-lowering treatment, with a relative risk of 0.84 (CI, 0.55 to 1.29) and an absolute risk reduction of 0.006 (CI, 0.008 to 0.019), did not lead to statistically significant improvements in the diabetes group. Secondary Prevention Eight trials reported on secondary prevention in patients with diabetes. The first, the Scandinavian Simvastatin Survival Study (4S), randomly assigned patients with coronary disease to simvastatin, 20 mg, or placebo (18). In a secondary analysis of the 202 patients with diabetes, simvastatin led to large benefits (relative risk for cardiovascular events, 0.50 [CI, 0.33 to 0.76]; absolute risk reduction, 0.23 [CI, 0.10 to 0.35]). Of note is the relatively high event rate in the control group (45%) compared with those seen in other trials. The Cholesterol and Recurrent Events (CARE) trial randomly assigned patients with previous myocardial infarction to pravastatin, 40 mg/d, or placebo (19). Pravastatin improved CHD outcomes in the 586 patients with diabetes (relative risk for cardiovascular events, 0.78 [CI, 0.62 to 0.99]; absolute risk reduction, 0.08 [CI, 0.01 to 0.16]). Results were reported as stratified by baseline LDL cholesterol levels and showed that for th

Screening for HIV in Health Care Settings: A Guidance Statement From the American College of Physicians and HIV Medicine Association

In this guideline, we will present the supporting evidence for and make specific recommendations on how clinicians evaluating acute sinusitis can differentiate bacterial causes from viral causes and how they can determine when the use of antibiotics is beneficial. The numbers in square brackets are cross-references to the numbered sections in the accompanying background paper, Principles of Appropriate Antibiotic Use for Acute Rhinosinusitis in Adults: Background, which is part 2 of this guideline (see pages 498-505). Acute Sinusitis The term sinusitis refers to inflammation of the mucosa of the paranasal sinuses. Because sinusitis is invariably accompanied by inflammation of the contiguous nasal mucosa, rhinosinusitis has become the preferred term. Rhinosinusitis is one of the 10 most common diagnoses in ambulatory practice and is the fifth most common diagnosis for which an antibiotic is prescribed. Primary care physicians tend to think of sinusitis as an acute bacterial infection and prescribe an antibiotic in 85% to 98% of cases. However, sinusitis is frequently caused by viral infection. It will often resolve in most patients without antibiotic treatment, even if it is bacterial in origin [1.0]. Acute rhinosinusitis is defined by symptom duration of less than 4 weeks. Acute bacterial sinusitis is usually a secondary infection resulting from sinus ostia obstruction, impaired mucus clearance mechanisms caused by an acute viral upper respiratory tract infection, or both. According to epidemiologic estimates, only 0.2% to 2% of viral upper respiratory tract infections in adults are complicated by bacterial rhinosinusitis. The gold standard for diagnosis of bacterial sinusitis is sinus puncture, and Streptococcus pneumoniae and Haemophilus influenzae are the bacteria most commonly isolated from infected maxillary sinuses. However, sinus puncture is an invasive procedure seldom performed in primary care. Because no simple and accurate office-based test for acute bacterial sinusitis exists, clinicians rely on clinical findings to make the diagnosis. However, signs and symptoms of acute bacterial sinusitis and those of prolonged viral upper respiratory tract infections are very similar, resulting in frequent misclassification of viral cases [1.1, 1.2]. Diagnosis: Bacterial Compared with Viral Overdiagnosis of acute bacterial rhinosinusitis is not surprising, considering the lack of specific clinical features that distinguish it from nonbacterial upper respiratory tract infections. Often, patients and physicians believe that an upper respiratory tract infection has gone on too long and that antibiotic treatment is therefore needed. In a study of the natural history of rhinovirus illness, length of illness ranged from 1 to 33 days. Most patients were well or nearly well in 7 to 10 days, and one fourth of patients were still symptomatic after 14 days. Bacterial rhinosinusitis is not common in patients whose symptoms have lasted less than 7 days; therefore, presence of symptoms for at least 7 days is a moderately sensitive but nonspecific predictor of bacterial rhinosinusitis [3.0]. Since 1976, seven investigators have published reports attempting to identify signs and symptoms specific to acute bacterial rhinosinusitis. All of these studies have limitations, such as a suboptimal gold standard or selection criteria that allowed the inclusion of patients whose symptoms had been present for more than 1 month. However, considering the results of all seven studies, purulent nasal discharge along with maxillary tooth or facial pain (especially when unilateral), unilateral sinus tenderness, and worsening of symptoms after initial improvement seem to be helpful findings for predicting a higher likelihood of bacterial infection in patients with rhinosinusitis-like symptoms [3.2]. Several investigators have studied the accuracy of sinus radiography in predicting the presence of purulent sinus fluid by using complete opacification, air-fluid level, or various degrees of mucosa thickening as the diagnostic criteria. Complete opacification and air-fluid level are the most specific findings, with specificities of 85% (range, 76% to 91%) and 80% (range, 71% to 87%), respectively. The finding of mucosal thickening has a low specificity, probably no better than that of skilled clinical judgment, which is 40% to 50%. The absence of all three findings has an estimated sensitivity of approximately 90% and is helpful in ruling out bacterial rhinosinusitis. Given these test characteristics and the known high prevalence of abnormal radiography findings in patients with viral rhinosinusitis, sinus radiography has limited value in routine diagnosis of acute bacterial rhinosinusitis [4.0]. Treatment For acute bacterial rhinosinusitis, randomized, double-blind, placebo-controlled trials of antibiotic treatment using pretreatment and post-treatment culture of sinus aspirates have not been performed. Five randomized, double-blind clinical trials with good methods have compared antibiotic treatment with placebo for acute rhinosinusitis in adults. Two recent meta-analyses, one under the auspices of the Cochrane Collaboration and the other under contract from the Agency for Healthcare Research and Quality (AHRQ), have recently been published. Both concluded that although antibiotics are statistically more efficacious than placebo in reducing or eliminating symptoms at 10 and 14 days, the effect size (degree of benefit) is relatively small. Moreover, most patients who receive placebo improve without antibiotic therapy. The AHRQ report pointed out that symptoms improved or resolved in 69% (CI, 57% to 79%) of patients by 14 days without any antibiotic treatment at all. When the 40% to 50% prevalence of bacterial rhinosinusitis in patients whose diagnosis is determined by signs and symptoms and the modest effectiveness of antibiotic treatment were considered, a cost-effectiveness model sponsored by the AHRQ favored antibiotic treatment for patients with moderate to severe symptoms and symptomatic treatment for those with mild symptoms [5.05.3]. Summary In summary, most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have purulent nasal secretions and maxillary facial or tooth pain or tenderness. Patients who have symptoms of rhinosinusitis for less than 7 days are unlikely to have bacterial infection. Sinus radiography is not recommended for diagnosis in routine cases. Acute bacterial rhinosinusitis resolves without antibiotic treatment in most cases. Symptomatic treatment and reassurance are the preferred initial management strategy for patients with mild symptoms. Antibiotic therapy should be reserved for patients with severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis, regardless of duration of illness. Initial antibiotic treatment should be with narrow-spectrum agents. On the basis of clinical trials, amoxicillin, doxycycline, and trimethoprimsulfamethoxazole are the favored antibiotics [5.4, 5.5]. Recommendations Recommendation 1. Sinus radiography is not recommended for the diagnosis of uncomplicated sinusitis. The greatest barrier to efficient antibiotic treatment of acute bacterial rhinosinusitis is lack of a simple and accurate diagnostic test. Until a better test is widely available in office practice, the office diagnosis of acute bacterial rhinosinusitis will remain imprecise. Duration of illness is a useful clinical criterion because acute bacterial sinusitis is not common in patients whose symptoms last for less than 7 days. Patients who do not have persistent purulent nasal drainage, maxillary facial or tooth pain or tenderness, or both are unlikely to have bacterial rhinosinusitis, regardless of duration of illness. Recommendation 2. Acute bacterial sinusitis does not require antibiotic treatment, especially if symptoms are mild or moderate. Because most patients with a clinical diagnosis of rhinosinusitis improve without antibiotic treatment, symptomatic treatment or reassurance is the preferred initial management strategy. Appropriate doses of analgesics, antipyretics, and decongestants should be offered, as well as patient education about the chosen management strategy. Recommendation 3. Patients with severe or persistent moderate symptoms and specific findings of bacterial sinusitis should be treated with antibiotics. Narrow-spectrum antibiotics are reasonable first-line agents. In most cases, antibiotics should be used only for patients with the specific findings of persistent purulent nasal discharge and facial pain or tenderness who are not improving after 7 days or those with severe symptoms of rhinosinusitis, regardless of duration. On the basis of clinical trials, amoxicillin, doxycycline, or trimethoprimsulfamethoxazole are the favored antibiotics.