Respiratory Illness: How to avoid antibiotic overuse through education

It’s that time of year again when respiratory illnesses show up around the community in higher numbers and provider’s offices, clinics, and emergency rooms are filling up with people seeking treatment. So, the question is do they need antibiotics or supportive care?

The Center for Disease Control and Prevention (CDC) and American Academy of Family Physicians (AAFP) lists respiratory infections as colds/runny nose, sore throat, excluding group A beta-hemolytic streptococcus (strep throat), COVID-19, influenza, bronchitis or a chest cold, middle ear infections, sinus infections, and pertussis, epiglottitis and laryngitis (1,2). So when might you need to prescribe an antibiotic? Antibiotics would be appropriate for patients who test positive for pertussis, strep throat, or have epiglottitis. However, for other respiratory infections, the need for an antibiotics is based on presentation, duration of symptoms and clinical judgement. Watchful waiting in adults with these symptoms is permissible depending on the patient situation and presentation. Supportive care is recommended with reliable follow-up in these situations(2,5,7).

Why does antibiotic usage matter? 

In a 2018 JAMA published study, 41% of nearly 15,000 patients with an acute respiratory illness at five United States sites were prescribed an antibiotic. After further investigation, 41% of those 6,136 patients, had a diagnosis that did not support the use of antibiotics (3). Another 2012 study out of Ontario, Canada with 185,000 patients seen for nonbacterial acute respiratory infection, showed 46% of those patients received antibiotics that were not warranted(4). The CDC estimates 41 million unnecessary antibiotic courses are prescribed in the U.S. every year1. The staggering number of unnecessary antibiotics prescribed for acute upper respiratory infections underscores the importance of rapid point-of-care testing for respiratory illnesses like influenza, COVID-19, RSV, and strep throat.

Interestingly, providers in their mid to late careers are more likely to prescribe an antibiotic. The lower prescribing rate for providers early in their career is likely due to better education around and understanding of Antibiotic Stewardship(4). Inappropriate use and overuse of antibiotics can have detrimental effects. Antimicrobial resistance is a real threat. Each year nearly three million people in the U.S. will become infected with an antibiotic resistant pathogen, and more than 35,000 die(1). 

Not only is antibiotic resistance threatening, but antibiotics come with some harsh risks and side effects. Allergic reaction are possible, and can be life threatening(1). The risk of acquiring Clostridioides difficile (C.difficile) increases greatly when on an antibiotic. The CDC estimates C.difficile is seven to 10 times more likely during and the month after a course of antibiotics. What’s worse is that one in 11 people over age 65 will die within one month of being diagnosed with healthcare-associated C.difficle(6).

Continuing education is the best way to avoid overuse

It is important to note that prescribing antibiotics is up to the discretion of the provider and their clinical judgement. As providers, continued education and knowing your resources is vital to your success. Below we have listed some excellent links to resources you can call on from treating respiratory illnesses, preventing transmission, viral respiratory pathogens and activity, and antimicrobial stewardship.

Norton Infectious Diseases Grand Rounds: When should antibiotics be prescribed?