Using antibiotics wisely for respiratory tract infection in the era of covid-19

What is best practice?

Table 1 summarises when patients should be assessed in person and when to prescribe antibiotics based on best available evidence related to RTI in primary care.56789 Among patients presenting with signs or symptoms compatible with covid-19, whether suspected or confirmed, most will have a mild self-limited illness that improves within a few days or up to two weeks.3 A systematic review of patients with covid-19 showed that even among the most critically ill, incidence of secondary bacterial infection is extremely low.4 A patient with RTI who is covid-19 negative usually still has a non-bacterial cause for their symptoms.1

Figure 1 outlines an approach to assessment and management of patients presenting with RTI based on their clinical presentations (based on table 1) and whether their symptoms and testing results are compatible with covid-19. Virtual care modalities can include synchronous (audio/video) and asynchronous (secure messaging) communication between physician and patients. These modalities are effective in communication regarding issues such as symptom management, potential treatment approaches, and test results; however, they may limit proper assessment and diagnosis.11 Most RTI syndromes are viral and can still be diagnosed and managed using virtual care. Conversely, bacterial RTI infections, which are the exception, generally require an in-person assessment to make an accurate diagnosis. For example, acute otitis media requires on otoscopic examination showing either a bulging tympanic membrane or a perforated tympanic membrane with purulent discharge.5 Acute bacterial pharyngitis requires isolation of Group A itreptococcus by culture or rapid testing, which should only be performed based on a validated predictive score that incorporates examination of the oropharynx and cervical nodes.6 A chest radiograph is required to diagnose bacterial pneumonia, because antibiotics based on history or examination alone will result in overtreatment.9 Finally, most sinusitis is viral, therefore bacterial sinusitis should only be considered among patients with at least seven days of symptoms who are having severe symptoms without improvement following trial of nasal corticosteroids.78

Fig 1

Proposed management of respiratory tract infection (RTI) in the era of virtual care and covid-19. Adapted from Choosing Wisely Canada10

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What are the barriers to judicious antibiotic prescribing?

The switch to virtual care may be a barrier to judicious prescribing of antibiotics for RTI during the covid-19 pandemic. Two retrospective studies that examined administrative databases found that the delivery of care virtually is associated with less diagnostic testing and more empiric antibiotic prescribing than in-person primary care.1213 Before the covid-19 pandemic, multiple other factors were known to be associated with unnecessary antibiotic prescribing for RTI. A systematic review of factors associated with antibiotic prescribing for RTI specifically identified 28 studies assessing predictors of antimicrobial use.14 Patient expectation for antibiotics was not associated with antibiotic prescribing (adjusted odds ratio 0.6-9.9), whereas the clinician’s perception that the patient or parent was expecting an antibiotic treatment was far more predictive (aOR 2.1-23.3). The role of physician perceptions of patient expectation for antibiotics in prescribing practices has suggested a need for communication strategies that physicians can use in navigating the clinical encounter with a patient. Time constraints associated with having such discussions with patients about why antibiotics are unnecessary are often cited as a barrier by clinicians. However, studies in both paediatric and adult patient populations show that these conversations do not substantially prolong visit duration compared with prescribing an antibiotic.15 Evaluation is limited regarding similar barriers in telemedicine and how the virtual clinical interaction affects conversations regarding unnecessary antibiotics.1116

What is the patient perspective?

Patients and family members are not necessarily seeking an antibiotic, but do want clear information about diagnosis, reassurance, safety net advice, and a treatment plan.17 This remains true in the era of covid-19, where many patients may be feeling heightened anxiety associated with the onset of RTI symptoms. Limited public awareness about the differences between a viral and bacterial infection alongside beliefs that antibiotics are low risk medications are drivers of unnecessary prescriptions in the outpatient setting.18 Patients and the general public are more receptive to communication that stresses the effect of antibiotic overuse on the individual, rather than harms to society.

How to improve practice

Making a practice change in antibiotic prescribing for RTI is not as much about knowing the right thing to do, as it is integrating the right evidence based clinical tools that support best practice. In cases without diagnostic uncertainty (for example, a positive test result for covid-19, or a clear alternative non-bacterial RTI diagnosis), clinicians should be able to avoid antibiotics completely by using structured communication that provides diagnostic clarity, identifies and addresses specific patient concerns, and offers a contingency plan.217Box 2 describes how to have these discussions with a patient.

In cases where a bacterial cause of infection is uncertain, such as acute otitis media or occasionally sinusitis, a delayed prescription can be used. The delayed prescription has been widely adopted in the UK and Spain. It involves a post-dated antibiotic prescription with instruction to fill the prescription only if symptoms do not improve. Since most patients have a self-limiting viral infection, fewer than one-third of patients fill the delayed prescription.19 Delayed prescriptions should not be used routinely for other suspected viral diagnoses, especially in the era of covid-19 where symptoms are expected to take up to 1-2 weeks to fully resolve.

A “viral prescription” is another tool that is increasingly used in Canada for any patient with suspected viral infection, although it has undergone limited evaluation to date.20 A viral prescription is a prescription pad outlining the diagnosis, why an antibiotic was not prescribed, symptom management, and evidence based supportive therapies, as well as a contingency plan should symptoms persist.17

The use of these tools can move the conversation away from antibiotic prescribing towards syndrome guided management of RTI and supporting shared decision making.21 These tools are often coupled with broader education and health literacy efforts to educate patients about antibiotic overuse through posters and plain language information. The covid-19 pandemic offers an opportunity to advance clinician practices and patient acceptability and health literacy regarding symptom management strategies and avoidance of antibiotics, given broad public interest and heightened awareness of viral respiratory infections.