Current evidence and gaps for outpatient respiratory tract infection diagnostics: a call to action

Executive Summary

Improving outpatient antibiotic stewardship programs (ASPs) for upper respiratory infections (URI)  is crucial in reducing unnecessary antibiotic use and mitigating antimicrobial resistance. While rapid diagnostic tests (RDTs) and point-of-care testing (POCT) show promise, their success depends on overcoming practical barriers, including costs, integration into workflows, and ongoing provider education. Future research should focus on evaluating these tools’ real-world effectiveness and exploring how to implement them more effectively across diverse healthcare settings.

Outpatient antibiotic use, which accounts for 80-90% of total antibiotic consumption, often leads to AMR, adverse events, and unnecessary costs. There is a strong need for outpatient ASPs to focus on diseases prone to overuse, such as URIs.

The CDC has developed core elements for outpatient ASPs, emphasizing commitment, policy action, tracking, and education. For URIs, it suggests targeting conditions where antibiotics are often over-prescribed, like acute bronchitis or viral pharyngitis.

Diagnostic tests, especially rapid diagnostic tests (RDTs), can help distinguish between viral and bacterial URIs, potentially reducing unnecessary antibiotic prescriptions. However, their implementation is hindered by challenges like staffing shortages, costs, and reimbursement issues.

URIs are mostly diagnosed based on symptoms and clinical findings and treatment is primarily symptom management with some therapeutic options (i.e., influenza antivirals). On the other hand, bacterial infections like pharyngitis, otitis media, and rhinosinusitis are treatable with antibiotics. In patients with viral infections, like those caused by SARS-CoV-2, influenza, or respiratory syncytial virus, antibiotics are not beneficial and potentially harmful. POCT for bacterial infections, especially Group A Streptococcus (GAS) for pharyngitis, has shown promise but is underused in some cases.

Successful outpatient ASPs include education for providers, patient communication strategies, feedback on prescribing behaviors, and leveraging RDTs for more accurate diagnoses. Studies have shown that interventions like these can reduce inappropriate antibiotic prescriptions, but long-term sustainability remains a challenge.

Key challenges include choosing the right tests, operationalizing testing platforms, costs, and integrating tests into outpatient workflows. CLIA-waived tests are seen as a promising option for improving access, but financial and policy barriers persist. The cost of tests and limited reimbursement for larger multiplex panels can restrict widespread adoption.

More research is needed to assess the real-world impact of RDTs and POCT in outpatient settings, especially in terms of cost-effectiveness, patient outcomes, and implementation barriers. ASPs should focus on using these technologies alongside robust AMS practices to improve overall antimicrobial use and patient outcomes.

Improving outpatient ASPs for URIs is crucial in reducing unnecessary antibiotic use and mitigating antibiotic resistance. While RDTs and POCT show promise, their success depends on overcoming practical barriers, including costs, integration into workflows, and ongoing provider education. Future research should focus on evaluating these tools’ real-world effectiveness and exploring how to implement them more effectively across diverse healthcare settings.

Authors:

Christen J. Arena^1,2, Holly M. Frost^3,4, Park Willis⁵, Brian Raux⁶, Minkey Wungwattana⁶, Michael P. Veve^1,2

1. Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
2. Department of Pharmacy, Henry Ford Hospital, Detroit, MI, USA
3. Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
4. Office of Research, Intermountain Health, Murray, UT, USA
5. Intermountain InstaCare, Intermountain Health, Salt Lake City, UT, USA
6. bioMérieux, US Medical Affairs, Salt Lake City, UT, USA