Using antibiotics wisely for respiratory tract infection in the era of covid-19
BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4125 (Published 13 November 2020) Cite this as: BMJ 2020;371:m4125Read our latest coverage of the coronavirus outbreak
- Jerome A Leis, infectious disease physician1 2 3 6,
- Karen B Born, health services researcher3,
- Guylene Theriault, primary care physician4,
- Olivia Ostrow, paediatric emergency physician5 6,
- Allan Grill, primary care physician7,
- K Brian Johnston, patient adviser8
- 1Division of Infectious Diseases and General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- 2Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- 3Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- 4Department of Family Medicine, McGill University, Montreal, Quebec, Canada
- 5Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- 6Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
- 7Department of Family Medicine, Markham Stouffville Hospital, Markham, Ontario, Canada; Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
- 8Quality of Care NL/Choosing Wisely NL, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
- Correspondence to JA Leis jerome.leis{at}sunnybrook.ca
What you need to know
Most acute respiratory tract infections (RTIs) are viral and can be managed through virtual care
For patients with RTI symptoms who test negative for covid-19, a diagnosis of viral RTI remains most likely, and supportive management can continue to be offered virtually in most cases
Virtual assessments limit diagnostic capabilities and can lead to overprescribing of unnecessary antibiotics. For those RTIs that may be bacterial, arrange an in-person assessment where possible to confirm the diagnosis (eg, to assess the tympanic membrane, to perform a test for Group A streptococcus, or to obtain a chest radiograph)
A 68 year old woman with history of chronic hypertension and type 2 diabetes calls her doctor’s office about a three day history of productive cough and fever. She is booked for an initial virtual visit with her doctor, who determines that she is not acutely unwell or short of breath and probably has viral bronchitis.
The doctor gives her a “viral prescription” (supportive management)by phone to help manage her symptoms, sends her for a nasopharyngeal swab for covid-19, and asks her to follow up within 48 hours if needed or any time if symptoms worsen. The next day, the woman calls because her symptoms are worse. She has received a negative test result for covid-19. An in-person assessment is booked to exclude bacterial pneumonia.
Unnecessary prescriptions of antibiotic medication result in preventable adverse drug reactions and are driving antimicrobial resistance—an international public health threat. Nearly half of all outpatient antibiotics are intended to treat respiratory tract infection (RTI), even though one third to half of these are inappropriately prescribed for patients without a bacterial respiratory infection.1
Before the covid-19 pandemic, international efforts such as the Choosing Wisely campaigns had focused on advancing improved antibiotic prescribing practices for the management of RTI (box …