Endorsing and Supporting Organizations Reference Articles

Endorsing Organizations Supporting Organizations Acute Bacterial Sinusitis: 2006/07 A D U L T

1. The Sinus and Allergy Health Partnership. Antimicrobial Treatment
American Academy of Urgent Care Medicine Aetna Health of California Inland Empire Health Plan Guidelines for Acute Bacterial Rhinosinusitis. Executive Summary.
American College of Physicians – California Blue Cross of California Kaiser Permanente SUPPLEMENT OTOLARYNGOLOGY-HEAD AND NECK SURGERY,
2004; 130: 1-45.
Association of California Nurse Leaders Blue Shield of California LA Care Health Plan
California Academy of Family Physicians CalOptima Molina Healthcare 2. Piccirillo, JF., Clinical Practice. Acute Bacterial Sinusitis.
California Academy of Physician Assistants Care 1st Health Plan National Medical Health N ENGL J MED. 2004 Aug 26; 351 (9): 902-10.
California Association of Nurse Practitioners Health Net of California Card Systems, Inc.
3. Snow, V. et. al., Clinical Practice Guideline Part 1: Principles
California Pharmacists Association Health Plan of San Joaquin Santa Barbara Regional of Appropriate Antibiotic Use of Acute Sinusitis in Adults:
California Society of Health-System Pharmacists Health Authority Background. ANNALS OF INTERNAL MEDICINE, 2001; 134:
Urgent Care Association of America 498-505.

Pharyngitis:
Over-the-Counter and Self Care for Viral Infections
Antibiotic treatment does not cure viral infections. Antibiotics can be harmful if they are given when not needed. The
treatments recommended below will help your patient feel better while their body’s own defenses are defeating the virus.
1. Institute for Clinical Systems Improvement. Acute Pharyngitis
Health Care Guideline. Executive Summary. www.ICSI.org.
May 2005.
AWARE is a project
of the California Acute
Respiratory
Medical Association
2. Cooper, R., et. al., Principles of Appropriate Antibiotic Use for Foundation,
The medicines below can be used according to the package instructions, or as directed by a healthcare provider. Acute Pharyngitis in Adults: Background. ANNALS OF INTERNAL in collaboration

Tract Infection
MEDICINE, 2001; 134: 509-517.
Symptoms Home Remedies Over-the-Counter with a number
Generic Name & Brand Name Examples 3. Bisno, A., et. al., Diagnosis and Management of Group A of clinical, public

Guideline
Fever, Aches • Sponge bath Analgesics Streptococcal Pharyngitis: A Practice Guideline – IDSA. CLINICAL
health and consumer
and Pain • Cool compress • Acetaminophen (Tylenol) INFECTIOUS DISEASES, 1997; 25: 574-583.
organizations designed
• Bed rest • Ibuprofen (Advil, Motrin IB, Nuprin)
Nonspecific Cough Illness/Acute Bronchitis:

Summary
• Heating pad on sore muscles • Naproxen (Aleve) to increase appropriate
1. Gonzales, R. et. al., Principles of Appropriate Antibiotic Use for
Treatment of Acute Respiratory Tract Infections in Adults. ANNALS antibiotic prescribing
Cough or • Drink more fluids Expectorant
Sore Throat • Room humidifier • Guaifenesin (Robitussin, Mucinex) OF EMERGENCY MEDICINE, 2001; 37: 690-697. (Reprinted from and lower antibiotic
ANNALS OF INTERNAL MEDICINE, March 2001)
• Gargle (warm salt water) Antitussives resistance in California. Developed as part of the
• Dextromethorphan (Delsym) 2. Gonzales, R., et. al., Principles of Appropriate Antibiotic Use Alliance Working for Antibiotic
for Treatment of Uncomplicated Acute Bronchitis: Background.
Combination Products ANNALS OF INTERNAL MEDICINE, 2001; 134: 521-529. Resistance Education (AWARE) Project.
• Robitussin DM
Stuffy or • Steam inhalation Decongestants 3. Hooton, T., Antimicrobial Resistance: A Plan of Action for
Runny Nose • Saline nose drops or spray • Pseudoephedrine (Sudafed) Community Practice. AMERICAN FAMILY PHYSICIAN, 2001; 63:
1034-1039.
• For red, raw nose, dab on petroleum • Oxymetazoline (Afrin)
jelly or salve or use tissues with lotion • Phenylephrine (Sudafed PE, Neo-Synephrine) NonSpecific URI:
Antihistamines 1. Gonzales, R. et. al., Principles of Appropriate Antibiotic Use for
Treatment of Acute Respiratory Tract Infections in Adults: Background,
• Loratadine (Alavert, Claritin)
Specific Aims and Methods. Clinical Practice Guideline. ANNALS
• Diphenhydramine (Benadryl) OF INTERNAL MEDICINE, 2001; 134: 479-486.
• Chlorpheniramine (Chlor-Trimeton)
• Clemastine (Tavist Allergy) 2. Gonzales, R., et. al., Principles of Appropriate Antibiotic Use
for Treatment of Acute Respiratory Tract Infections in Adults:
Antiviral Therapies for Influenza Background. Clinical Practice Guideline Part 2. ANNALS OF
Given within 48 hours of the onset of flu symptoms oseltamivir and zanamivir can reduce the duration of uncomplicated INTERNAL MEDICINE, 2001; 134: 490-494.
influenza A and influenza B. These agents are also effective in preventing influenza and may be CONSIDERED for unvaccinated CMA Foundation
persons or those vaccinated after the start of local influenza activity. 3. Gonzales, R. et. al., Antibiotic Prescribing for Adults with Colds,
1201 J Street, Suite 350
Upper Respiratory Tract Infections, and Bronchitis by Ambulatory
Care Physicians. JAMA, September 17, 1997; 278: 901-904. Sacramento, CA 95814
916.551.2550 voice
This compendium was designed to summarize appropriate antibiotic treatment of common adult outpatient infections. 916.551.2544 fax
For more information visit our website at:
It is based on guidelines and recommendations from leading medical experts and professional organizations in the U.S. www.aware.md
This guideline summary is updated annually. www.aware.md © CMA Foundation 2006
 CMA Foundation AWARE Project Adult Clinical Practice Guidelines Compendium Summary
Organizational
Illness Indications for Antibiotic Treatment Pathogen Antimicrobial Therapy Antibiotic Guidelines Reviewed
Acute When to Treat with an Antibiotic: Diagnosis of acute bacterial sinusitis may be Streptococcus Antibiotic duration: 10 to 14 days 1st Line: American Academy of
Bacterial made in adults with symptoms of a viral URI that have not improved after 10 days pneumoniae • Amoxicillin Allergy, Asthma &
Sinusitis or that worsen after 5-7 days. Failure to respond after 72 hours of antibiotics: Immunology (AAAAI)
nontypeable Haemophilus Reevaluate patient and switch to alternate antibiotics. Alternatives:
• Amoxicillin-clavulanate American Academy of
Diagnosis May Include Some or All of the Following Symptoms or Signs: influenzae
• Cefpodoxime Family Physicians (AAFP)
Nasal drainage, nasal congestion, facial pressure/pain (especially when unilateral
and focused in the region of a particular sinus), postnasal discharge, anosmia, fever, Moraxella catarrhalis • Cefuroxime American College of
cough, maxillary dental pain, ear pressure/fullness. Less frequent signs and symptoms • Cefdinir Physicians (ACP)
include hyposmia and fatigue, in conjunction with some or all of the above. • Respiratory quinolones (levofloxacin,
moxifloxacin) Centers for Disease Control
When Not to Treat with an Antibiotic: Nearly all cases of acute bacterial sinusitis Mainly viral pathogens and Prevention (CDC)
resolve without antibiotics. Antibiotic use should be reserved for moderate symptoms For ß-Lactam Allergy: Sinus and Allergy
that are not improving after 10 days, or that are worsening after 5-7 days, and severe Trimethoprim-sulfamethoxazole Health Partnership (SAHP)
symptoms. doxycycline, azithromycin, clarithromycin

Pharyngitis When to Treat with an Antibiotic: Streptococcus pyogenes (Group A Strep): Streptococcus pyogenes Group A Strep: 1st Line: ACP
Symptoms of sore throat, fever, headache. Antibiotic Duration: 10 days • Penicillin V
• Benzathine penicillin G CDC
Physical Findings Include: Fever, tonsillopharyngeal erythema and exudates, palatal Infectious Diseases
petechiae, tender and enlarged anterior cervical lymph nodes, and absence of cough. Alternatives: Society
Confirm diagnosis with throat culture or rapid antigen detection before using antibiotics; • Amoxicillin of America (IDSA)
negative rapid antigen detection tests may be confirmed with a throat culture. • Oral cephalosporins
• Clindamycin Institute for Clinical
When Not to Treat with an Antibiotic: Most pharyngitis cases are viral in origin. Routine respiratory Systems Improvement
The presence of the following is uncommon with Group A Strep, and point away from viruses For ß-Lactam Allergy: (ICSI)
using antibiotics: conjunctivitis, cough, rhinorrhea, diarrhea, and absence of fever. • Erythromycin

Nonspecific When to Treat with an Antibiotic: Antibiotics not indicated in patients with Bordetella pertussis Uncomplicated: Not indicated Uncomplicated: Not indicated AAFP
Cough Illness/ uncomplicated acute bacterial bronchitis. Sputum characteristics not helpful in ACP
determining need for antibiotics. Treatment is reserved for patients with acute bacterial Chlamydophila pneumoniae Chronic COPD: CDC
Acute
exacerbation of chronic bronchitis and COPD, usually smokers. In patients with severe • Amoxicillin, trimethoprim- IDSA
Bronchitis Mycoplasma pneumoniae sulfamethoxazole or doxycycline
symptoms, rule out other more severe conditions, e.g. pneumonia.

When Not to Treat with an Antibiotic: 90% of cases are nonbacterial. Literature Mainly viral pathogens Other:
fails to support use of antibiotics in adults without history of chronic bronchitis or other • Bordetella pertussis, Chlamydophila
co-morbid conditions. pneumonia, Mycoplasma pneumonia -
erythromycin or doxycyline

Nonspecific When Not to Treat with an Antibiotic: Antibiotics not indicated; however, nonspecific Viral Not indicated Not indicated AAFP
URI URI is a major cause of acute respiratory illnesses presenting to primary care practitioners. ACP
Patients often present expecting some treatment. Attempt to discourage antibiotic CDC
use and explain appropriate treatment. ICSI
IDSA
Empiric Therapy
Outpatient When to Treat with an Antibiotic as an Outpatient: Perform CXR to confirm Streptococcus No recent antibiotics Antibiotic use within 3 months* 1st Line: IDSA
Community- the diagnosis of pneumonia especially if patient has 2 or more signs or symptoms: pneumoniae Respiratory quinolone or • Macrolides (azithromycin, ICSI
Healthy Macrolide
Acquired Temp > 100 F (37.8 C), pulse > 100, decreased breath sounds, rales, RR > 20. combination of advanced erythromycin or clarithromycin)
If CXR shows infiltrate, consider pre-existing conditions and calculate Atypical pathogens: macrolide with either high • Respiratory quinolones (levofloxacin,
Pneumonia Mycoplasma
Pneumonia Severity Index (PSI < 90 for outpatient management). Visit dose amoxicillin or moxifloxacin)
(CAP) http://pda.ahrq.gov/clinic/psi/psi.htm to download PDA version of PSI. pneumoniae, amoxicillin-clavulanate
Sputum gram stain and culture are desirable. Chlamydophila ß-Lactam Alternatives:
Co-morbid** Advanced macrolide Respiratory quinolone or
pneumoniae, or respiratory • High dose amoxicillin
combination of advanced
When Not to Treat with an Antibiotic as an Outpatient: Consider inpatient admission Legionella species quinolone macrolide with a ß-lactam • High dose amoxicillin-clavulanate
if PSI score > 90, unable to tolerate orals, unstable social situation, or if clinical • Oral cephalosporins (cefpodoxime,
judgment so indicates. Haemophilus *Choose a class of antibiotic that differs from the prior antibiotic
cefprozil, cefuroxime)
influenzae **COPD, diabetes, renal disease or CHF, or malignancy

Advanced macrolide includes azithromycin or clarithromycin

Antibiotic duration: 7-14 days (5 days for azithromycin and
levofloxacin), 10-21 days for Legionnaires’ disease
�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������