American Academy of Family Physicians Clinical Practice Guidelines Sore Throat Cough Ear Pain
Guidelines for the Use of Antibiotics in Acute Upper Respiratory Tract Infections
Am Fam Medico. 2006 Sep fifteen;74(six):956-966.
Patient information: See related handout on when to use antibiotics, written past the authors of this commodity.
Commodity Sections
- Abstruse
- Guideline Development Process
- Otitis Media in Children
- Astute Bacterial Rhinosinusitis
- Acute Pharyngitis
- Acute Bronchitis
- Nonspecific Upper Respiratory Tract Infection
- Influenza
- Applied Strategies for Reducing Inappropriate Antibiotic Use
- References
To help physicians with the advisable utilise of antibiotics in children and adults with upper respiratory tract infection, a multidisciplinary team evaluated existing guidelines and summarized cardinal practice points. Astute otitis media in children should exist diagnosed only if in that location is sharp onset, signs of middle ear effusion, and symptoms of inflammation. A period of observation without immediate use of antibiotics is an selection for certain children. In patients with sinus infection, acute bacterial rhinosinusitis should be diagnosed and treated with antibiotics only if symptoms take non improved later on 10 days or accept worsened after 5 to 7 days. In patients with sore throat, a diagnosis of grouping A beta-hemolytic streptococcus pharyngitis generally requires confirmation with rapid antigen testing, although other guidelines allow for empiric therapy if a validated clinical rule suggests a loftier likelihood of infection. Astute bronchitis in otherwise salubrious adults should not exist treated with antibiotics; delayed prescriptions may help ease patient fears and simultaneously reduce inappropriate utilize of antibiotics.
The Centers for Disease Control and Prevention (CDC) estimates that more than 100 million antibiotic prescriptions are written each year in the ambulatory intendance setting.1 With so many prescriptions written each year, inappropriate antibody use will promote resistance. In addition to antibiotics prescribed for upper respiratory tract infections with viral etiologies, wide-spectrum antibiotics are used too often when a narrow-spectrum antibody would have been just as effective.ii This misuse of antibiotics has led to the development of antibiotic-resistant leaner.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Clinical criteria that aid in the diagnosis of acute otitis media include the abrupt onset of signs and symptoms, the presence of eye ear effusion, and signs or symptoms of eye ear inflammation. | C | 6 |
| A period of observation is appropriate for select children with acute otitis media and nonsevere symptoms. | C | 6 |
| A diagnosis of acute bacterial rhinosinusitis should be considered in patients with symptoms of a viral upper respiratory infection that have non improved after ten days or that worsen after five to seven days. | C | vii |
| Treatment of sinus infection with antibiotics in the kickoff week of symptoms is not recommended. | C | 7 |
| Amantadine (Symmetrel) and rimantadine (Flumadine) should not be used for the handling of flu because of widespread resistance. | A | 23 |
| Acute bronchitis in otherwise healthy adults should non be treated with antibiotics. | A | 14 |
| Telling patients not to fill an antibiotic prescription unless symptoms worsen or fail to improve afterwards several days tin reduce the inappropriate utilise of antibiotics. | B | 24,25 |
In one report, upwards to 50 pct of parents had a previsit expectation of receiving an antibiotic prescription for their children, and 1 third of physicians perceived an expectation for a prescription.3 Because of these expectations and the time constraints on physicians, prescribing an antibiotic may seem preferable to explaining why an antibiotic is unnecessary. Still, researchers have plant no association between receiving an antibiotic prescription and satisfaction with the office visit. What does impact satisfaction is whether patients understood their illness subsequently the visit and whether they felt that their physician spent enough fourth dimension with them.
Increased antibiotic resistance is not inevitable. For instance, Republic of finland demonstrated the success of a nationwide effort to reduce antibiotic resistance following an increase in erythromycin resistance among patients with group A streptococci in the early 1990s.4 Nationwide recommendations were developed for the appropriate apply of macrolide antibiotics; these efforts led to a reduction in the employ of macrolides and a subsequent decrease in the charge per unit of erythromycin resistance.
This article presents guidelines that were developed by the Brotherhood Working for Antibiotic Resistance Education (Enlightened) Project, with back up from the California Medical Association Foundation. This projection began in Jan 2000. More than eighty organizations are partners in the AWARE Projection (http://www.aware.physician). The piece of work group is composed of practicing physicians, academic physicians, pharmacists, and nurses. No ane from the pharmaceutical industry was involved in the development of the compendia.
Given the latitude of this topic, the focus of this article is on the appropriate use of antibiotics and non on the use of adjunctive treatments such every bit antitussives, decongestants, and inhalers, although they play an important role in affliction direction and symptomatic relief. The guidelines discussed hither address the care of otherwise healthy patients without major comorbidities in the outpatient setting.
Guideline Development Process
- Abstract
- Guideline Development Process
- Otitis Media in Children
- Astute Bacterial Rhinosinusitis
- Acute Pharyngitis
- Acute Bronchitis
- Nonspecific Upper Respiratory Tract Infection
- Influenza
- Practical Strategies for Reducing Inappropriate Antibiotic Use
- References
A work group was formed in late 2001 to provide overall direction in the evolution of clinical practise materials and resources. The process began with a literature search for each respiratory tract infection. Adjacent, the do guidelines developed for each affliction past the leading medical organizations were compiled. Members of the work grouping then prioritized the reference articles and guidelines to be included in the review process. The compendia are shown in Tables 1 and ii.5
TABLE 1
Clinical Practice Guidelines Compendium: Children with URI
| Illness/pathogen | Indications for antibiotic handling | Treatment | Antibiotic |
|---|---|---|---|
| Otitis media Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis | When to care for with an antibiotic:
| Historic period group
| First-line therapy
|
| Acute bacterial sinusitis S. pneumoniae, nontypeable H. influenzae, G. catarrhalis | When to care for with an antibiotic:
|
| Beginning-line therapy
|
| Pharyngitis Streptococcus pyogenes, routine respiratory viruses | When to treat with an antibody:
|
| First-line therapy
|
| Nonspecific coughing affliction/bronchitis > ninety percentage of cases caused past routine respiratory viruses < ten percent of cases caused by Bordetella pertussis, Chlamydia pneumoniae, or Mycoplasma pneumoniae | When to care for with an antibiotic:
|
|
|
| Bronchiolitis/nonspecific URI > 200 viruses, including rhinoviruses, coronaviruses, adenoviruses, respiratory syncytial virus, enteroviruses (coxsackieviruses and echoviruses), influenza viruses, and parainfluenza virus | When not to care for with an antibiotic:
|
|
|
Tabular array 2
Clinical Practice Guidelines Compendium: Adults with URI
| Disease/pathogen | Indications for antibiotic treatment | Handling | Antibiotic |
|---|---|---|---|
| Acute bacterial sinusitis Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis, mainly viral pathogens | When to care for with an antibiotic: diagnosis may be made in adults with symptoms of a viral upper respiratory infection that accept non improved later x days or that worsen after five to seven days. Diagnosis may include some or all of the following: nasal drainage, nasal congestion, facial force per unit area or pain (especially when unilateral and focused in the region of a particular sinus), postnasal discharge, hyposmia, anosmia, fever, cough, fatigue, maxillary dental hurting, ear pressure or fullness. |
| First-line therapy
|
| When not to treat with an antibody: nearly all cases resolve without antibiotics. Antibiotic use should be reserved for moderate symptoms that are not improving later 10 days or that worsen after 5 to seven days, and severe symptoms. | |||
| Pharyngitis Streptococcus pyogenes, routine respiratory viruses | When to care for with an antibiotic: S. pyogenes (group A streptococcus infection). Symptoms of sore throat, fever, headache. Concrete findings include fever, tonsillopharyngeal erythema and exudates, palatal petechiae, tender and enlarged anterior cervical lymph nodes, and absence of cough. Confirm diagnosis with pharynx culture or rapid antigen testing earlier using antibiotics; negative rapid antigen examination results may be confirmed with throat civilisation. |
| Offset-line therapy
|
| When not to care for with an antibiotic: most pharyngitis cases are viral in origin. The presence of the following is uncommon with group A streptococcal infection and points away from using antibiotics: conjunctivitis, cough, rhinorrhea, diarrhea, and absenteeism of fever. | |||
| Nonspecific cough disease/acute bronchitis Bordetella pertussis, Chlamydia pneumoniae/Mycoplasma pneumoniae | When to treat with an antibiotic: antibiotics not indicated in patients with uncomplicated acute bacterial bronchitis. Sputum characteristics not helpful in determining demand for antibiotics. Treatment is reserved for patients with astute bacterial exacerbation of chronic bronchitis and COPD, normally smokers. In patients with astringent symptoms, rule out other more serious conditions (e.k., pneumonia). |
|
|
| When not to care for with an antibiotic: 90 percent of cases are nonbacterial. Literature fails to support use of antibiotics in adults without history of chronic bronchitis or other comorbid status. | |||
| Nonspecific upper respiratory infection Viral | When non to treat with an antibody: Antibiotics not indicated; however, nonspecific upper respiratory infection is a major etiologic crusade of acute respiratory illnesses presenting to master care physicians. Patients often expect treatment. Try to discourage antibiotic use and explicate appropriate treatment. |
|
|
| Influenza Flu virus | When not to treat with an antibiotic: antibiotics not indicated. For acute treatment, supportive and symptomatic care is the standard. Characterized past sharp onset of ramble and respiratory signs and symptoms such as fever, myalgia, headache, rhinitis, astringent malaise, nonproductive cough, and sore pharynx.. |
|
|
| The incubation period for influenza is one to four days, with an boilerplate of 2 days. Adults typically are infectious from the day before symptoms begin through approximately five days later on onset of affliction |
Otitis Media in Children
- Abstract
- Guideline Development Procedure
- Otitis Media in Children
- Astute Bacterial Rhinosinusitis
- Acute Pharyngitis
- Astute Bronchitis
- Nonspecific Upper Respiratory Tract Infection
- Flu
- Practical Strategies for Reducing Inappropriate Antibiotic Use
- References
The American Academy of Family Physicians (AAFP)/American University of Pediatrics (AAP) guideline for otitis media in children focuses on three major points: accurate diagnosis, an cess of hurting, and judicious use of antibiotics with an option for watchful waiting in select patients.6
ACCURATE DIAGNOSIS
Three elements must be met to confirm the diagnosis of acute otitis media. The first chemical element is the contempo, usually abrupt onset of signs and symptoms of middle ear inflammation and effusion. The second element is the presence of middle ear effusion equally indicated by jutting of the tympanic membrane, limited or absent-minded mobility of the tympanic membrane, air fluid level backside the tympanic membrane, or otorrhea. The concluding element to be considered is the presence of signs or symptoms of middle ear inflammation as indicated by erythema of the tympanic membrane or otalgia.6
PAIN ASSESSMENT
Effective therapies for the pain of otitis media include acetaminophen and ibuprofen. Topical agents such as benzocaine, domicile remedies such as oil, and the awarding of oestrus or cold also may exist helpful. Symptomatic relief is of import to maximize patient comfort and to minimize sick days.
Antibiotic THERAPY VS. WATCHFUL WAITING
The AAFP/AAP guideline introduces the option of watchful waiting in select patients with simple astute otitis media. The decision is based on the patient'southward age, disease severity, and the certainty of the diagnosis. Severe illness is defined as moderate to severe otalgia or temperature greater than 102°F (39°C) in the by 24 hours, whereas nonsevere illness is defined as mild otalgia and temperature less than 102° F.
A menstruation of watchful waiting with close clinical follow-up is an option for children six months to ii years of age with nonsevere symptoms and an uncertain diagnosis. Information technology is also an option for older children with nonsevere symptoms, regardless of the certainty of diagnosis. For all other children, antibiotics are recommended.
If an antibiotic is prescribed, first-line therapy for patients with nonsevere disease is high-dosage amoxicillin (80 to 90 mg per kg per day). Patients with nonsevere affliction in whom amoxicillin therapy has failed should switch to high-dosage amoxicillin/clavulanate (Augmentin; 80 to 90 mg per kg per day of the amoxicillin component). For patients with symptoms of severe infection, outset-line therapy is high-dosage amoxicillin/clavulanate (80 to 90 mg per kg per day for the amoxicillin component). Alternative therapies for patients allergic to penicillin are shown in Table 1.5
Otitis media with effusion is defined as fluid in the middle ear space but without the symptoms of an acute infection; antibiotic therapy is not required. Otitis media with effusion may exist caused past a viral upper respiratory infection or may be a effect of acute otitis media. If the diagnostic criteria for acute otitis media are absent-minded, patients who have otitis media with effusion should be observed.
Acute Bacterial Rhinosinusitis
- Abstract
- Guideline Development Process
- Otitis Media in Children
- Acute Bacterial Rhinosinusitis
- Acute Pharyngitis
- Acute Bronchitis
- Nonspecific Upper Respiratory Tract Infection
- Flu
- Practical Strategies for Reducing Inappropriate Antibiotic Use
- References
Upper respiratory infections and acute bacterial rhinosinusitis in adults and children often have similar symptoms. The principal pathogens are identical to those that cause acute otitis media: Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis. A diagnosis of acute bacterial rhinosinusitis may be made in children and adults with symptoms of a viral upper respiratory infection that take not improved after 10 days or that worsen after five to seven days.7 Patients may have some or all of the following symptoms: nasal drainage, nasal congestion, facial pressure or pain, postnasal drainage, hyposmia or anosmia, fever, cough, fatigue, maxillary dental pain, and ear pressure or fullness. Because many of these signs and symptoms are nonspecific, accurate diagnosis of acute bacterial rhinosinusitis is challenging. A validated clinical conclusion dominion for adults that combines several symptoms is shown in Table 3.eight
TABLE 3
Berg Prediction Dominion for Acute Bacterial Rhinosinusitis
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The Sinus and Allergy Health Partnership issued guidelines targeting patients with mild to moderate illness.7 Treatment of sinus infection with antibiotics during the starting time week of symptoms is not recommended considering the infection typically is not bacterial at that point. Handling is reserved for patients who accept symptoms for more than x days or who experience worsening symptoms.
For children, treatment options include high-dosage amoxicillin, high-dosage amoxicillin/clavulanate, cefpodoxime (Vantin), cefuroxime (Ceftin), cefdinir (Omnicef), or ceftriaxone (Rocephin). Trimethoprim/sulfamethoxazole (TMP-SMX; Bactrim, Septra), macrolides, or clindamycin (Cleocin) is recommended if the patient has a history of type I hypersensitivity reaction to betalactam antibiotics. Type I immunoglobulin E–mediated reactions can lead to anaphylaxis and angioedema.
For adults, handling options include high-dosage amoxicillin, high-dosage amoxicillin/clavulanate, cefpodoxime, cefdinir, gatif loxacin (Tequin), levof loxacin (Levaquin), and moxif loxacin (Avelox). TMP-SMX, doxycycline (Vibramycin), azithromycin (Zithromax), or clarithromycin (Biaxin) is recommended if the patient has a history of type I hypersensitivity reaction to betalactam antibiotics.
If the patient does not respond to antimicrobial therapy afterward 72 hours, he or she should exist reevaluated and a change in antibiotics should exist considered. Diagnostic evaluations such as computed tomography, fiberoptic endoscopy, or sinus aspiration also may be necessary for patients who experience a treatment failure.
Astute Pharyngitis
- Abstract
- Guideline Development Process
- Otitis Media in Children
- Acute Bacterial Rhinosinusitis
- Acute Pharyngitis
- Acute Bronchitis
- Nonspecific Upper Respiratory Tract Infection
- Influenza
- Applied Strategies for Reducing Inappropriate Antibiotic Use
- References
Most patients with sore pharynx from an infectious cause have a virus. Symptoms that suggest a viral etiology for sore throat include conjunctivitis, cough, coryza, and diarrhea. Group A beta-hemolytic streptococcus (GABHS) pharyngitis accounts for 15 to 30 percentage of pharyngitis cases in children and approximately x percent in adults.9 The AWARE guideline recommends rapid antigen testing or throat culture for any patient with suspected GABHS pharyngitis and antibody therapy just if the patient tests positive for GABHS.
An evidence-based guideline sponsored past the American College of Physicians (ACP) and the CDC provides a somewhat different approach to antibiotic apply and laboratory testing in adults with acute tonsillopharyngitis.10 It recommends that physicians stratify the risk of GABHS pharyngitis using a validated clinical prediction rule such every bit that provided inTable 4.eleven
TABLE four
Strep Score for Grouping A Beta-Hemolytic Streptococcus Pharyngitis
| Symptom | Points | |
|---|---|---|
| Fever | + 1 | |
| Absence of cough | + 1 | |
| Cervical adenopathy | + i | |
| Tonsillar exudates | + ane | |
| Patient's age | ||
| < xv years | + 1 | |
| 15 to 45 years | 0 | |
| > 45 years | – 1 | |
| Total score: | ______ | |
| Score | Probability of strep (%) | Action |
|---|---|---|
| – 1 or 0 | 1 | No farther testing or handling |
| ane, 2, or 3 | 10 to 35 | Rapid antigen testing; treatment based on event |
| four or v | 51 | Consider empiric treatment or rapid antigen testing |
Using the strep score, GABHS pharyngitis can be ruled out clinically in depression-risk patients and no further testing is needed. Moderate-adventure patients need rapid antigen testing to ostend the diagnosis before therapy is initiated, whereas empiric therapy can exist considered for loftier-risk patients. Co-ordinate to the ACP/CDC guideline, a pharynx civilisation is rarely indicated in the master evaluation of adult patients. Throat culture is recommended just in an outbreak state of affairs as a method of epidemiologic written report and for patients in whom gonococcal illness is possible.10
Penicillin, in a 10-mean solar day course of penicillin 5 (Veetids) or a single dose of parenteral penicillin Yard benzathine (Bicillin LA), remains the treatment of choice for GABHS pharyngitis. However, amoxicillin is an acceptable alternative because of taste and the increased likelihood of compliance. Alternative antimicrobials include first- or second-generation cephalosporins, clindamycin, or macrolides. A meta-analysis published since the AWARE guidelines were compiled found a small-scale do good to handling with cephalosporins over penicillin in patients with GABHS pharyngitis.12
Astute Bronchitis
- Abstract
- Guideline Evolution Process
- Otitis Media in Children
- Acute Bacterial Rhinosinusitis
- Acute Pharyngitis
- Acute Bronchitis
- Nonspecific Upper Respiratory Tract Infection
- Influenza
- Practical Strategies for Reducing Inappropriate Antibody Utilize
- References
Bronchitis is inflammation of the bronchial respiratory mucosa leading to a productive cough. The diagnosis is based on clinical findings, and no objective test exists. Sputum characteristics (i.east., green versus clear versus absent-minded) are not useful in differentiating a bacterial or viral etiology.13 More than 90 percentage of cases of simple astute bronchitis accept nonbacterial etiologies.xiv Therefore, antibiotics usually are non indicated for nonspecific cough illness. If pneumonia is suspected based on tachypnea, high fever, disproportionate breath sounds, or other symptoms, the diagnosis should be confirmed with breast radiography earlier antibiotics are prescribed.15
The results of recent randomized controlled trials back up this recommendation. For instance, in 1 study, patients diagnosed with acute bronchitis were randomized to treatment with azithromycin or placebo (vitamin C).sixteen At that place was no significant divergence in clinical outcomes betwixt the groups after iii or seven days.
Another report of 807 patients with acute lower respiratory tract infection, including many with fever or purulent sputum, compared treatment outcomes with an immediate antibiotic, a delayed antibody, or no antibody. No significant differences were noted between groups, and the researchers concluded that no antibiotics and delayed antibiotics were both acceptable approaches.17 Finally, a systematic review published in 2004 found a modest benefit at best in the groups treated with antibiotics, and this was balanced by an equally smashing harm because of adverse furnishings.18
If the cough is prolonged for more than 10 days, a bacterial etiology should be considered.19,20 Bordetella pertussis, Mycoplasma pneumoniae, and Chlamydia pneumoniae are possible causes, and macrolide antibiotics are the handling of selection. The CDC recommends azithromycin for five days, clarithromycin for seven days, or erythromycin for 14 days in children older than one month and in adults with suspected pertussis based on recent exposure or for postexposure prophylaxis. For children younger than one month, azithromycin is recommended. TMP-SMX is an alternative for infants older than two months.21
Nonspecific Upper Respiratory Tract Infection
- Abstract
- Guideline Development Process
- Otitis Media in Children
- Astute Bacterial Rhinosinusitis
- Acute Pharyngitis
- Astute Bronchitis
- Nonspecific Upper Respiratory Tract Infection
- Influenza
- Practical Strategies for Reducing Inappropriate Antibiotic Employ
- References
Nonspecific upper respiratory tract infection presents with symptoms that ofttimes are referred to equally the common cold.20 Causative agents include numerous viruses such every bit rhinoviruses, adenoviruses, respiratory syncytial viruses, parainfluenza viruses, and enteroviruses. Antibiotics are not needed in these circumstances. Treatment consists of adequate fluid intake, rest, humidified air, and over-the-counter analgesics and antipyretics.
Influenza
- Abstract
- Guideline Development Procedure
- Otitis Media in Children
- Acute Bacterial Rhinosinusitis
- Acute Pharyngitis
- Astute Bronchitis
- Nonspecific Upper Respiratory Tract Infection
- Influenza
- Practical Strategies for Reducing Inappropriate Antibody Use
- References
Flu is characterized by the abrupt onset of fever, myalgias, headache, rhinitis, severe angst, nonproductive coughing, and sore throat. The main treatment is supportive care to relieve symptoms. Antiviral medications (i.east., amantadine [Symmetrel], rimantadine [Flumadine], oseltamivir [Tamiflu], and zanamivir [Relenza]) can decrease the elapsing of symptoms by approximately 24 hours merely are effective only when given within the beginning 36 hours of illness.22 A recent advisory from the CDC recommends that physicians no longer use amantadine or rimantadine considering of widespread resistance.23
Practical Strategies for Reducing Inappropriate Antibiotic Utilise
- Abstract
- Guideline Development Procedure
- Otitis Media in Children
- Acute Bacterial Rhinosinusitis
- Acute Pharyngitis
- Acute Bronchitis
- Nonspecific Upper Respiratory Tract Infection
- Influenza
- Practical Strategies for Reducing Inappropriate Antibiotic Utilize
- References
Patients frequently expect an antibiotic for an acute respiratory infection; because health intendance professionals strive for patient satisfaction, they may feel pressured to prescribe an unnecessary antibiotic. If the diagnosis is a viral illness, the physician needs to have a contingency plan to explicate to the patient why an antibiotic will not be prescribed. Patients should be educated nearly the difference betwixt bacterial and viral infections and why antibiotics will exist ineffective for a viral illness. Targeted symptomatic relief tin can be provided with antipyretics, decongestants, antihistamines, and antitussives. Having prescription pads with a preprinted checklist of medications for symptomatic relief and patient instruction is useful.
Several studies have indicated that giving patients an antibiotic prescription and telling them not to fill it unless their symptoms worsen or do not improve after several days has been shown to reduce antibody use.24,25 Developing an easy-access follow-upward visit for patients who practice not improve may alleviate some of the anxieties associated with non getting an antibiotic. An educational intervention such as instructing patients on the advisable indications for antibiotic employ tin help maintain patient satisfaction without prescribing antibiotics. More than information on educational materials is available athttp://www.aware.dr..
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REFERENCES
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iii. Hamm RM, Hicks RJ, Bemben DA . Antibiotics and respiratory infections: are patients more satisfied when expectations are met? J Fam Pract. 1996;43:56–62.
4. Seppala H, Klaukka T, Vuopio-Varkila J, Muotiala A, Helenius H, Lager Grand, et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Republic of finland. Finnish Study Group for Antimicrobial Resistance. Due north Engl J Med. 1997;337:441–vi.
5. California Medical Association Foundation. Alliance Working for Antibiotic Resistance Education (Aware) clinical practice guidelines. Accessed August three, 2006, at: http://world wide web.aware.dr./clinical/clinical_guide.asp.
6. American Academy of Pediatrics Subcommittee on Direction of Astute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113:1451–65.
vii. Anon JB, Jacobs MR, Poole Dr., Ambrose PG, Benninger MS, Hadley JA, et al., for the Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis [Published correction appears in Otolaryngol Head Neck Surg 2004;130:794–6]. Otolaryngol Head Cervix Surg. 2004;130(1 suppl):1–45.
8. Berg O, Carenfelt C. Analysis of symptoms and clinical signs in the maxillary sinus empyema. Acta Otolaryngol. 1988;105:343–9.
nine. Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH, for the Infectious Diseases Society of America. Exercise guidelines for the diagnosis and direction of group A streptococcal pharyngitis. Clin Infect Dis. 2002;35:113–25.
10. Cooper RJ, Hoffman JR, Bartlett JG, Besser RE, Gonzales R, Hickner JM, et al., for the American Academy of Family Physicians, American Higher of Physicians–American Order of Internal Medicine, Centers for Disease Control and Prevention. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med. 2001;134:509–17.
eleven. Ebell MH. Strep pharynx. Am Fam Physician. 2003;68:937–8.
12. Casey JR, Pichichero ME. Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children. Pediatrics. 2004;113:866–82.
13. Chodosh S. Acute bacterial exacerbations in bronchitis and asthma. Am J Med. 1987;82:154–63.
14. Gonzales R, Bartlett JG, Besser RE, Cooper RJ, Hickner JM, Hoffman JR, et al., for the American Academy of Family Physicians, American College of Physicians–American Society of Internal Medicine, Centers for Disease Control and Prevention, Infectious Diseases Guild of America. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med. 2001;134:521–nine.
15. Snowfall Five, Mottur-Pilson C, Gonzales R. Principles of appropriate antibiotic use for handling of acute bronchitis in adults. Ann Intern Med. 2001;134:518–20.
16. Evans AT, Husain S, Durairaj L, Sadowski LS, Charles-Damte Grand, Wang Y. Azithromycin for acute bronchitis: a randomised, double-blind, controlled trial. Lancet. 2002;359:1648–54.
17. Little P, Rumsby Thousand, Kelly J, Watson L, Moore K, Warner G, et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA. 2005;293:3029–35.
18. Smucny J, Fahey T, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2004;(four):CD000245.
19. O'Brien KL, Dowell SF, Schwartz B, Marcy SM, Phillips WR, Gerber MA. Cough illness/bronchitis—principles of judicious apply of antimicrobial agents. Pediatrics. 1998;101:178–81.
20. Dowell SF, Schwartz B, Phillips WR. Appropriate employ of antibiotics for URIs in children: Part Ii. Cough, pharyngitis and the mutual cold. The Pediatric URI Consensus Team. Am Fam Physician. 1998;58:1335–42.,1345
21. Tiwari T, Potato TV, Moran J, for the National Immunization Program, CDC. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC guidelines. MMWR Recomm Rep. 2005;54(RR-fourteen):1–sixteen.
22. Montalto NJ, Mucilage KD, Ashley JV. Updated treatment for influenza A and B. Am Fam Physician. 2000;62:2467–76.
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25. Arroll B, Kenealy T, Kerse N. Do delayed prescriptions reduce antibiotic use in respiratory tract infections? A systematic review [Published correction appears in Br J Gen Pract 2004;54:138]. Br J Gen Pract. 2003;53:871–vii.
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