A critical assessment of published guidelines and other decision‐support systems for the antibiotic treatment of community‐acquired respiratory tract infections

Abstract

Guidelines are an important means by which professional associations and governments have sought to improve the quality and cost-effectiveness of disease management for infectious diseases. Prescribing of initial antibiotic therapy for community-acquired respiratory tract infections (RTIs) is primarily empiric and physicians may often have a limited appreciation of bacterial resistance. Recent guidelines for managing RTIs have adopted a more evidence-based approach. This process has highlighted important gaps in the existing knowledge base, e.g. concerning the impact of resistance on the effectiveness of oral antibiotics for outpatient community-acquired pneumonia and the level of resistance that should prompt a change in empiric prescribing. In upper RTIs, the challenge is to identify patients in whom antibiotic therapy is warranted. Concentrated, sustained efforts are needed to secure physicians' use of guidelines. The information should be distilled into a simple format available at the point of prescribing and supported by other behavioral change techniques (e.g. educational outreach visits). Advances in information technology offer the promise of more dynamic, computer-assisted forms of guidance. Thus, RTI prescribing guidelines and other prescribing support systems should help control bacterial resistance in the community. However, their effect on resistance patterns is largely unknown and there is an urgent need for collaborative research in this area. Rapid, cost-effective diagnostic techniques are also required and new antibiotics will continue to have a role in disease management.

Double-Blind, Randomized Study of the Efficacy and Safety of Oral Pharmacokinetically Enhanced Amoxicillin-Clavulanate (2,000/125 Milligrams) versus Those of Amoxicillin-Clavulanate (875/125 Milligrams), Both Given Twice Daily for 7 Days, in Treatment of Bacterial Community-Acquired Pneumonia in Adults

“…A total of 143 patients in the intent-to-treat population met the eligibility criteria (i.e., clinical symptoms at screening representative of community-acquired pneumonia caused by typical pathogens) yet were only seropositive for atypical pathogens. It is possible that these patients were infected by typical pathogens which could not be cultured (i.e., the sputum Gram stain requirements of Ͼ25 white blood cells and Ͻ10 squamous epithelial cells per field at 100ϫ magnification were not met for sputum samples), as yields on sputum cultures in communityacquired pneumonia patients are low (11,19).…”

Revolutionizing Clinical Microbiology Laboratory Organization in Hospitals with In Situ Point-of-Care

“…Although this organization is cost-effective, the distance from the laboratories to the site of patient care and the batch processing of clinical specimens make rapid turn-around times impossible [3], [6]. Consequently, microbiology laboratories are unable to contribute to timely decision-making for most infectious diseases [6]-[8], resulting in unnecessary treatment and hospitalization [9] as well as the empiric use of antibiotics.…”

Empirical treatment of influenza-associated pneumonia in primary care: a descriptive study of the antimicrobial susceptibility of lower respiratory tract bacteria (England, Wales and Northern Ireland, January 2007-March 2010)

“…Examination of pathological specimens from the 1918–1919 influenza pandemic suggested that secondary bacterial infection was the major cause of deaths associated with influenza-like illness (ILI) during that pandemic 3. The prognosis of patients presenting with bacterial pneumonia rapidly worsens with delay in treatment, and effective empirical treatment (before or in the absence of a specific microbiological diagnosis) is therefore a critical aspect of successful pandemic influenza planning 4 5…”