Inappropriate antibiotic use for ARTI is an important contributor to antibiotic resistance – 41% of the 100 million annual antibiotic prescriptions are for such conditions. This increased antibiotic use can be directly correlated with the emergence of antibiotic-resistant infections and a large number of medication-related adverse events.

TABLE 1: Common ARTI conditions that should not be treated with antibiotics:

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Condition Summary Determining the likelihood of a bacterial infection Appropriate management strategies High-Value Care Advice
Acute uncomplicated bronchitis A self-limited inflammation of the bronchi with a cough lasting up to 6 weeks. Often accompanied by mild constitutional symptoms Nonviral pathogens – including Mycoplasma pneumonia, Chlamydophila pneumonia, or Bordetella pertussis – may be present. Acute bronchitis must be distinguished from pneumonia, which is unlikely in healthy immunocompetent adults younger than 70 years, absent the following clinical criteria: tachycardia, tachypnea, fever, and abnormal findings on a chest examination. Recent clinical guidelines recommend against routine antibiotic treatment in the absence of pneumonia. Patients may receive symptomatic relief from cough suppressants, expectorants, first-generation antihistamines, decongestants, and β-agonists. Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected
Pharyngitis A benign, self-limited illness characterized by a sore throat made worse with swallowing, with or without constitutional symptoms. Most cases of pharyngitis have a viral origin. Patients presenting with a sore throat and associated symptoms – cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, or oropharyngeal lesions – are more likely to have a viral illness; no further testing is necessary. Providers must rule out group A Streptococcus. Patients presenting with unusually severe signs and symptoms – difficulty swallowing, neck tenderness, drooling, or swelling – should be evaluated for rare throat infections. 2012 guidelines from the Infectious Diseases Society of America (IDSA) recommend antibiotic therapy only for patients with a positive streptococcal test result. Adult patients presenting with a sore throat should be offered analgesic therapy – aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs, or throat lozenges – which can reduce pain. Typical course of this sore throat is less than 1 week. Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis (for example, persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate combination of symptoms) by rapid antigen detection test and/or culture for group A Streptococcus. Clinicians should treat patients with antibiotics only if they have confirmed streptococcal pharyngitis.
Acute rhinosinusitis A self-limited illness resulting from viral infection, allergy, or irritant that causes inflammation of the mucosal tissue in the nasal and paranasal sinus cavity. Symptoms include nasal congestion and obstruction, purulent nasal discharge, maxillary tooth pain, facial pain or pressure, fever, fatigue, cough, hyposmia or anosmia, ear pressure, headache, and halitosis. Acute rhinosinusitis is usually caused by a viral pathogen. Acute bacterial rhinosinusitis (ABRS) is a secondary infection resulting from obstruction of the sinus ostia and leading to impaired mucosal clearance. This is the result of a viral upper respiratory tract infection (URI) – fewer than 2% of viral URIs are complicated by ABRS. Clinical guidelines recommend using clinical signs and symptoms to differentiate bacterial causes, which is more likely when patients present with symptoms lasting more than 10 days and including fever, purulent nasal discharge, facial pain lasting >3 consecutive days, or double sickening for more than 3 days. Empirical antibiotics are recommended immediately after a clinical diagnosis of ABRS is established based on existing clinical criteria. Amoxicillin-clavulanate is the preferred treatment; doxycycline or respiratory fluoroquinolone may be used as an alternative. The American Academy of Otolaryngology emphasizes watchful waiting in lieu of antibiotic therapy as initial management for all patients with uncomplicated ABRS. Supportive care for acute uncomplicated rhinosinusitis includes analgesics for pain and antipyretics for fever. Topical decongestants, saline nasal irrigation, mycolytics, intranasal corticosteroids, and antihistamines may offer additional relief. Clinicians should reserve antibiotic treatment for acute rhinosinusitits for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39°) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening).
Common cold (nonspecific upper respiratory infection) A benign, self-limited virus that may include sneezing, rhinorrhea, sore throat, low-grade fever, headache, and malaise. Complications of the common cold include acute bacterial sinusitis, asthma exacerbation, and otitis media. These complications would not be prevented by antibiotic use. Multiple seasonal viruses have been associated with the common cold. Symptomatic therapy is the most appropriate management strategy; antibiotics are not effective and should not be prescribed. Symptoms may last up to 2 weeks, and symptomatic therapy – antihistamine, analgesic, decongestant – may offer relief. Clinicians should not prescribe antibiotics for patients with the common cold.