The September issue of Annals of Internal Medicine published guidelines from the American College of Physicians / American Society of Internal Medicine (ACP / ASIM) and the Centers for Disease Control and Prevention (CDC ) on the rational use of antibiotics in the treatment of acute diseases. respiratory infections in adults.

The main objective of these publications is to prevent the unreasonable prescription of antibiotics on an outpatient basis and, therefore, to reduce the level of antibiotic resistance.

In most cases (75% of all prescriptions), antibiotics are prescribed on an outpatient basis for the treatment of acute sinusitis, acute pharyngitis, acute bronchitis, and non-specific upper respiratory tract infections, including treatment of colds and runny nose.

After analyzing the material of 7 controlled studies, the authors were convinced that with this pathology, the appointment of antibiotics is inappropriate, because in most cases, upper respiratory tract infections are viral in nature and bacterial complications are very rare.

Most acute sinusitis is caused by viruses and only 0.2-2% of them are complicated by bacterial infection. Many SARS patients have symptoms of sinusitis, which go away on their own within 7-10 days. If the disease lasts more than 7 days, bacterial sinusitis may be suspected. The Cochrane Library has a meta-analysis dedicated to prescribing antibiotics for sinusitis and showing the reliable but insignificant benefits of using antibacterial drugs. According to clinical manifestations, it is practically impossible to distinguish between viral sinusitis and bacterial sinusitis, and a cultural study is not informative, except when the research material is obtained by sinus puncture, which is rarely done.

In normal situations, there is no need to do an X-ray or CT scan of the sinuses. The culture obtained from the secretion of the nasal cavity is not informative and antibiotics should only be prescribed if the infection persists for more than 7 days or when persistent symptoms of bacterial sinusitis appear, such as purulent discharge nose and facial pain.

It should be taken into account that the differences in the recommendations for the use of antibiotics between ACP / ASIM and CDC are insignificant: in case of sinusitis of a bacterial nature, amoxicillin, doxycycline or cotrimoxazole must be prescribed. The CDC does not claim the benefit of any antibiotics, but they argue that it is better to use narrow spectrum antibiotics that are active against S. pneumoniae and H. influenzae. The ACP / ASIM recommendations do not provide a theoretical assessment of the antibiotic sensitivity of the main agents responsible for sinusitis, but nevertheless, the data from controlled clinical trials are analyzed at a fairly high level, which is more preferable in this case. case.

The only clinical case where it is necessary to prescribe antibiotics is pharyngitis caused by group A streptococcus (5 to 15% of all pharyngitis in adults).

The clinical criteria for the bacterial etiology of pharyngitis are: inflammation of the tonsils, enlarged cervical lymph nodes, fever and absence of cough. If the patient has all 4 criteria, antibiotic therapy may be prescribed empirically. The presence of two or three of the listed criteria + a positive test for group A streptococcus are an indication for the appointment of antibiotics. Patients who have one or none of the specified criteria do not require a streptococcal antigen test and antibiotic therapy.

The choice of antibiotic is quite simple: penicillin or erythromycin, if there is a history of allergic reactions to β-lactams.

The ACP / ASIM and CDC recommendations were limited only to the treatment of acute bronchitis in adult patients without chronic lung disease and immunodeficiencies. The main agents responsible for acute bronchitis are viruses (influenza, parainfluenza, respiratory syncytial virus, coronavirus, adenovirus, rhinovirus). Only 5% to 10% of the diseases are caused by M. pneumoniae, C. pneumoniae and Bordetélla pertussis. In a routine sputum test, these pathogens are not detected. In such cases, the main objective is to exclude pneumonia, therefore an X-ray examination is recommended if the cough is disturbing for 3 weeks or if there are clinical signs of lung damage and other symptoms of pneumonia.

Antibacterial drugs are recommended only for patients with pertussis, who may be suspected of coughing for more than 3 weeks and, most importantly, in the event of an appropriate outbreak.

The ACP / ASIM recommendations and the CDC recommendations contain a section on the treatment of influenza with antiviral drugs in cases where no more than 48 hours have passed since the onset of the symptoms of the disease. The recommendations do not contain information on influenza vaccination and the appointment of antiviral drugs to people who have been in close contact with people with the flu.