Adult Outpatient Treatment Recommendations

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The table below summarizes the most recent recommendations for appropriate antibiotic prescribing for adults seeking care in an outpatient setting. Antibiotic prescribing guidelines establish standards of care and focus quality improvement efforts.

The table also offers information related to over-the-counter medication for symptomatic therapy. Over-the-counter medications can provide symptom relief, but have not been shown to shorten the duration of illness. They also have a low incidence of minor adverse effects. Providers and patients should weigh the potential for benefits and minor adverse effects when considering symptomatic therapy.

 

Adult Treatment Recommendations
Condition Epidemiology Diagnosis Management
Acute rhinosinusitis1,2
  • About 1 out of 8 adults (12%) in 2012 reported receiving a diagnosis of rhinosinusitis in the previous 12 months, resulting in more than 30 million diagnoses
  • Ninety–98% of rhinosinusitis cases are viral, and antibiotics are not guaranteed to help even if the causative agent is bacterial.
  • Diagnose acute bacterial rhinosinusitis based on symptoms that are:
    • Severe (>3-4 days), such as a fever ≥39°C (102°F) and purulent nasal discharge or facial pain;
    • Persistent (>10 days) without improvement, such as nasal discharge or daytime cough; or
    • Worsening (3-4 days) such as worsening or new onset fever, daytime cough, or nasal discharge after initial improvement of a viral upper respiratory infections (URI) lasting 5-6 days.
  • Sinus radiographs are not routinely recommended.
 If a bacterial infection is established:
  • Watchful waiting is encouraged for uncomplicated cases for which reliable follow-up is available.
  • Amoxicillin or amoxicillin/clavulanate is the recommended first-line therapy.
  • Macrolides such as azithromycin are not recommended due to high levels of Streptococcus pneumoniae antibiotic resistance (~40%).
  • For penicillin-allergic patients, doxycycline or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) are recommended as alternative agents.
Acute uncomplicated bronchitis3–5
  • Cough is the most common symptom for which adult patients visit their primary care provider, and acute bronchitis is the most common diagnosis in these patients.
  • Evaluation should focus on ruling out pneumonia, which is rare among otherwise healthy adults in the absence of abnormal vital signs (heart rate ≥ 100 beats/min, respiratory rate ≥ 24 breaths/min, or oral temperature≥ 38 °C) and abnormal lung examination findings (focal consolidation, egophony, fremitus).
  • Colored sputum does not indicate bacterial infection.
  • For most cases, chest radiography is not indicated.
 Routine treatment of uncomplicated acute bronchitis with antibiotics is not recommended, regardless of cough duration.

Options for symptomatic therapy include:

  • Cough suppressants (codeine, dextromethorphan);
  • First-generation antihistamines (diphenhydramine);
  • Decongestants (phenylephrine).

Evidence supporting specific symptomatic therapies is limited.
Common cold or non-specific upper respiratory tract infection (URI)6,7
  • The common cold is the third most frequent diagnosis in office visits, and most adults experience two to four colds annually.
  • At least 200 viruses can cause the common cold.
  • Prominent cold symptoms include fever, cough, rhinorrhea, nasal congestion, postnasal drip, sore throat, headache, and myalgias.
  • Decongestants (pseudoephedrine and phenylephrine) combined with a first-generation antihistamine may provide short-term symptom relief of nasal symptoms and cough.
  • Non-steroidal anti-inflammatory drugs can be given to relieve symptoms.
  • Evidence is lacking to support antihistamines (as monotherapy), opioids, intranasal corticosteroids, and nasal saline irrigation as effective treatments for cold symptom relief.

Providers and patients must weigh the benefits and harms of symptomatic therapy.
Pharyngitis8,9
  • Group A beta-hemolytic streptococcal (GAS) infection is the only common indication for antibiotic therapy for sore throat cases.
  • Only 5–10% of adult sore throat cases are caused by GAS.
  • Clinical features alone do not distinguish between GAS and viral pharyngitis; a rapid antigen detection test (RADT) is necessary to establish a GAS pharyngitis diagnosis
  • Those who meet two or more Centor criteria (e.g., fever, tonsillar exudates, tender cervical lymphadenopathy, absence of cough) should receive a RADT. Throat cultures are not routinely recommended for adults.
  • Antibiotic treatment is NOT recommended for patients with negative RADT results.
  • Amoxicillin and penicillin remain first-line therapy due to their reliable antibiotic activity against GAS.
  • For penicillin-allergic patients, cephalexin, cefadroxil, clindamycin, or macrolides are recommended.
  • GAS antibiotic resistance to azithromycin and clindamycin are increasingly common.
  • Recommended treatment course for all oral beta lactams is 10 days.
  • For specific treatment recommendations and dosing, visit the Pharyngitis (Strep Throat) page for clinicians.
Acute uncomplicated cystitis10,11
  • Cystitis is among the most common infections in women and is usually caused by E. coli.
  • Classic symptoms include dysuria, frequent voiding of small volumes, and urinary urgency. Hematuria and suprapubic discomfort are less common.
  • Nitrites and leukocyte esterase are the most accurate indicators of acute uncomplicated cystitis
 For acute uncomplicated cystitis in healthy adult non-pregnant, premenopausal women:
  • Nitrofurantoin, trimethoprim/sulfamethoxazole (TMP-SMX, where local resistance is <20%), and fosfomycin are appropriate first-line agents.
  • Fluoroquinolones (e.g. ciprofloxacin) should be reserved for situations in which other agents are not appropriate.

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References

  1. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (updated): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 Suppl):S1-39.
  2. Chow AW, Benninger MS, Itzhak B, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72-e112.
  3. Albert RH. Diagnosis and treatment of acute bronchitis. Am Fam Physician. 2010;82(11):1345-50.
  4. Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl).
  5. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: Background. Ann Intern Med. 2001;134(6):521-9.
  6. Fashner J, Ericson K, Werner S. Treatment of the common cold in children and adults. Am Fam Physician. 2012;86(2):153-9.
  7. Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl): 72S-74S.
  8. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86-102.
  9. Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Ann Intern Med. 2001;134(6):509-17.
  10. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-20.
  11. Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011;84(7):771-6.

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