Primary Care

Don’t prescribe antibiotics in vaccinated children more than 6 months old and adults in whom you suspect acute otitis media, unless there is either a perforated tympanic membrane with purulent discharge or a bulging tympanic membrane with one of the three following criteria:

• Fever (≥39°C)

• Moderately or severely ill

• Significant symptoms lasting > 48 hours

Don’t routinely prescribe antibiotics unless the patient’s modified Centor score is ≥ 2 AND throat swab culture (or rapid antigen test if available) confirms presence of Group A Streptococcus.

Don’t perform throat swabs at all for patients with Centor score ≤ 1, OR if there are symptoms of a viral infection such as rhinorrhea, oral ulcers or hoarseness.

Don’t prescribe antibiotics unless symptoms have persisted for greater than 7-10 days without improvement.

Differentiating viral rhinosinusitis (VRS) from acute bacterial rhinosinusitis (ABRS) can be challenging. Patients not meeting the below criteria are best managed with a viral prescription.

Antibiotics should only be considered if the patient has at least 2 of the below PODS symptoms, one of those being O or D, AND the patient meets one of the following criteria:

• The symptoms are severe

• The symptoms are mild to moderate symptoms if there is no response after a 72 hours trial with nasal corticosteroids.

P: Facial Pain/pressure/fullness
O: Nasal Obstruction
D: Purulent/discolored nasal or postnasal Discharge
S: Hyposmia/anosmia (Smell)

Don’t prescribe antibiotics for pneumonia unless there is objective evidence.

If access to a chest x-ray is available near your clinic, don’t routinely prescribe antibiotics for suspected pneumonia without confirming the presence of a new consolidation.

Physical examination alone, demonstrating respiratory crackles, is not sufficient to establish a diagnosis of pneumonia and initiate antibiotics in the majority of situations. Patients with no vital sign abnormalities and a normal respiratory examination are unlikely to have pneumonia and most likely don’t need a chest x-ray.

Don’t routinely prescribe antibiotics for exacerbations of Chronic Obstructive Pulmonary Disease unless there is clear increase in sputum purulence with either increase in sputum volume and/or increased dyspnea.

Common Myth:

• Routine prescription of antibiotic in all COPD exacerbations will prevent complications: antibiotics only prevent complications in select COPD exacerbations populations, with the greatest benefits in ICU admitted patients.

Facts:

• In most cases, oral corticosteroids are beneficial, whether or not the patient meets criteria for antibiotics. Short course of corticosteroids (5 days) is as effective as longer course for COPD exacerbations.

Don’t prescribe antibiotics unless there is clear evidence of secondary bacterial infection (see the recommendations for otitis media, pharyngitis, sinusitis, pneumonia).

Common Myth: When patients seek a consultation for URTI symptoms it is because they want antibiotics.

Information and clear instructions about symptom control will meet most patient’s expectations.

Don’t prescribe antibiotics unless there is clear evidence of secondary bacterial infection (see the recommendations for otitis media, pharyngitis, sinusitis, pneumonia).

Don’t prescribe antibiotics for bronchitis/asthma/bronchiolitis exacerbations.

Common Myths:

• Antibiotics will prevent complications: there is no difference in clinical improvement with or without antibiotics.

• My patient is still coughing after 14 days, it must be bacterial: The cough may last up to 3 weeks in 50% of patients and even more than a month for 25%.

• Greenish sputum is an indication of a bacterial infection:

the appearance of the sputum cannot be used to distinguish between viral and bacterial bronchitis.