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Diagnosis and treatment of upper respiratory tract infections in the primary care setting.

BACKGROUND: Acute respiratory tract infections such as acute exacerbations of chronic bronchitis (AECB), acute otitis media (AOM), and acute bacterial rhinosinusitis (ABRS) account for approximately 75% of antibiotic prescriptions written and are among the leading reasons for physician office visits in the United States. Resistance of the predominant pathogens in respiratory tract infections (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) to available antibiotics has led clinicians to reevaluate the diagnosis and management of these infections.

OBJECTIVE: The purpose of this review is to provide primary care practitioners with an accessible combined resource for the management of AECB, AOM, and ABRS.

METHODS: This review was based on discussions from a roundtable meeting (sponsored by an educational grant from GlaxoSmithKline) that convened clinicians versed in the management of upper and lower respiratory tract infections. In addition, primary articles were identified by a MEDLINE search and through secondary sources.

RESULTS: To reduce the prevalence of resistance, judicious and appropriate use of antibiotics must be implemented in clinical practice. With accurate diagnosis of bacterial and nonbacterial conditions, and patient education on antibiotic use and misuse, the excessive use of antibiotics and ensuing resistance can be reduced. The incorporation of pharmacokinetic and pharmacodynamic data with minimum inhibitory concentration values can provide a more comprehensive assessment of antibiotic activity in vivo. Stratification of patients with AECB according to patient characteristics and frequency of exacerbation can be used to determine which patients will benefit from antibiotic treatment and to guide clinicians in their choice of antibiotic. The Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group has issued recommendations on the management of AOM based on prior antibiotic therapy, which is a risk factor for antimicrobial resistance. The Sinus and Allergy Health Partnership guidelines for the treatment of ABRS in adults and children are based on the predicted efficacy of various antibiotics as well as patient age, severity of disease, likelihood of bacterial infection, likelihood of spontaneous resolution, and in vitro susceptibility of the predominant pathogens based on pharmacokinetic and pharmacodynamic breakpoints.

CONCLUSIONS: Guidelines for the management of AECB, AOM, and ABRS emphasize the importance of differentiating between bacterial and nonbacterial infections, choosing an antibiotic based on the likelihood of infection with resistant pathogens, and providing coverage against the predominant pathogens. The judicious use of antibiotics also has been identified as an instrumental part of controlling unnecessary antibiotic use and subsequent resistance.

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