Managing Acute Respiratory Tract Infections

Managing Acute Respiratory Tract Infections
Author Information (click to view)

Amir Qaseem, MD, PhD

Director, Department of Clinical Policy

American College of Physicians


Amir Qaseem, MD, PhD (click to view)

Amir Qaseem, MD, PhD

Director, Department of Clinical Policy

American College of Physicians

The American College of Physicians (ACP) and CDC has released a guideline on the appropriate use of antibiotics for ARTIs in adults.

Acute respiratory tract infections (ARTIs) are one of the most common reasons for acute outpatient physician office visits and antibiotic prescriptions among adults in the United States. “Inappropriate use of antibiotics for ARTIs is an important contributor to antibiotic resistance, an urgent public health threat, and costs the U.S. economy billions of dollars each year,” says Amir Qaseem, MD, PhD. “Efforts to reduce the inappropriate prescribing of these drugs in the ambulatory setting is a priority.” These efforts are necessary to improve quality of care, lower healthcare costs, and slow and prevent the continued rise in antibiotic resistance.

Authors of the new guideline, which was published in Annals of Internal Medicine and is available online at, conducted an extensive literature review of evidence about appropriate antibiotic use for ARTI in adults. “According to CDC, 50% of antibiotic prescriptions may be unnecessary or inappropriate in the outpatient setting,” says Dr. Qaseem, who was one of the authors of the guidelines. “The recommendations in this paper are important to help stopping the unnecessary and inappropriate use of antibiotics for ARTIs.”

Four Key Points

According to Dr. Qaseem, the guideline from ACP and the CDC provide four key points of advice in an effort to promote high-value care:

  1. Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected. Providers and patients should weigh the benefits and potential for adverse effects when considering symptomatic therapy for these individuals.
  2. Clinicians should test patients with symptoms that are suggestive of group A streptococcal pharyngitis using a rapid antigen detection test and/or culture. For example, this testing should conducted in patients with persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate combination of symptoms. “Antibiotic treatment should be reserved for patients who have confirmed streptococcal pharyngitis,” says Dr. Qaseem.
  3. Antibiotics should be reserved for acute rhinosinusitis for patients with persistent symptoms that last for more than 10 days, onset of severe symptoms or signs of a high fever (>39°C), and purulent nasal discharge or facial pain that lasts at least 3 consecutive days. Another time to use antibiotics is at the onset of worsening symptoms following a typical viral illness that lasts 5 days that was initially improving.
  4. Clinicians should not prescribe antibiotics for the common cold. “The common cold typically clears up without the need for antibiotics,” Dr. Qaseem says.

A Multifaceted Strategy

According to Dr. Qaseem, reducing antibiotic prescriptions on a larger scale will require a multidimensional approach at both the community and national levels. “These strategies should combine physician, patient, and public education efforts,” he says. “It’s everyone’s responsibility to use antibiotics responsibly and appropriately. Clinicians should take the time to explain to patients why or why not antibiotics are being prescribed. Healthcare providers have the power to control prescriptions and help the cause by reducing inappropriate antibiotic prescribing.”

Amir Qaseem, MD, PhD, has indicated to Physician’s Weekly that he has no financial interests to disclose.

Readings & Resources (click to view)

Harris AM, Hicks LA, Qaseem A, for the High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Ann Intern Med. 2016 Jan 16 [Epub ahead of print]. Available at:

Hicks LA, Taylor TH Jr, Hunkler RJ. U.S. outpatient antibiotic prescribing, 2010 [Letter]. N Engl J Med. 2013; 368:1461-1462.

Hersh AL, Jackson MA, Hicks LA, American Academy of Pediatrics Committee on Infectious Diseases. Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Pediatrics. 2013; 132:1146-1154.

Gonzales R, Bartlett JG, Besser RE, Hickner JM, Hoffman JR, Sande MA, American Academy of Family Physicians. Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults: background. Ann Intern Med. 2001; 134:490-494.

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