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Upper respiratory tract infections are responsible for millions of physician visits in the United States annually. Although viruses cause most acute upper respiratory tract infections, studies show that many infections are unnecessarily treated with antibiotics. Because inappropriate antibiotic use results in adverse events, contributes to antibiotic resistance, and adds unnecessary costs, family physicians must take an evidence-based, judicious approach to the use of antibiotics in patients with upper respiratory tract infections. Antibiotics should not be used for the common cold, influenza, COVID-19, or laryngitis. Evidence supports antibiotic use in most cases of acute otitis media, group A beta-hemolytic streptococcal pharyngitis, and epiglottitis and in a limited percentage of acute rhinosinusitis cases. Several evidence-based strategies have been identified to improve the appropriateness of antibiotic prescribing for acute upper respiratory tract infections.

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Chronic nonallergic rhinitis encompasses a group of rhinitis subtypes without allergic or infectious etiologies. Although chronic nonallergic rhinitis represents about one-fourth of rhinitis cases and impacts 20 to 30 million patients in the United States, its pathophysiology is unclear and diagnostic testing is not available. Characteristics such as no evidence of allergy or defined triggers help define clinical subtypes. There are eight subtypes with overlapping presentations, including nonallergic rhinopathy, nonallergic rhinitis with nasal eosinophilia syndrome, atrophic rhinitis, senile or geriatric rhinitis, gustatory rhinitis, drug-induced rhinitis, hormonal rhinitis, and occupational rhinitis. Treatment is symptom-driven and similar to that of allergic rhinitis. Patients should avoid known triggers when possible. First-line therapies include intranasal corticosteroids, intranasal antihistamines, and intranasal ipratropium. Combination therapy with decongestants and first-generation antihistamines can be considered if monotherapy does not adequately control symptoms. Nasal irrigation and intranasal capsaicin may be helpful but need further investigation.

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Allergic rhinitis is a common and chronic immunoglobulin E-mediated respiratory illness that can affect quality of life and productivity, as well as exacerbate other conditions such as asthma. Treatment should be based on the patient's age and severity of symptoms. Patients should be educated about their condition and advised to avoid known allergens. Intranasal corticosteroids are the most effective treatment and should be first-line therapy for persistent symptoms affecting quality of life. More severe disease that does not respond to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation. Subcutaneous or sublingual immunotherapy should be considered if usual treatments do not adequately control symptoms and in patients with allergic asthma. Evidence does not support the use of mite-proof impermeable mattresses and pillow covers, breastfeeding, air filtration systems, or delayed exposure to solid foods in infancy or to pets in childhood.

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BACKGROUND: Pregnancy is a high-risk indication for influenza vaccination; however, rates of vaccination fall short of Centers for Disease Control and Prevention-recommended guidelines. METHODS: Brief educational sessions with family physicians and obstetricians were undertaken in the fall of 2002. Notes reading "Think Flu Vaccine" were placed on active obstetric charts during the study period. Charts were reviewed at the end of influenza season for documentation of discussion or administration of influenza vaccination. Charts for the same period during the previous 2 years were also reviewed for baseline. RESULTS: Baseline rates of vaccination or discussion averaged 1.5% over the 2000-2002 influenza seasons. After intervention, the 2002-2003 rate of vaccination or discussion demonstrated an almost 15-fold increase to 21.9%. This was greater in family practices (3.2% to 44.9%) versus obstetric practices (1.2% to 19.4%), and in small (3.3% to 46.7%) versus large (1.1% to 16%) practices (all values were P < .001). CONCLUSIONS: Provider education with simple chart prompts seems an effective way to increase rates of physician discussion of influenza vaccination with pregnant women. The increased rates seen in this study across various practice settings also suggest that inclusion of influenza vaccination on standardized prenatal care flowsheets may achieve similar goals with less individualized effort and should be considered.

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PURPOSE: The Centers for Disease Control (CDC) identify women in their second and third trimesters as a high-risk population warranting influenza vaccination. This study attempted to characterize understanding of these guidelines and obstacles to their implementation in a suburban community. METHODS: Family physicians and obstetricians with admitting privileges to a community-based hospital were surveyed regarding estimated vaccine availability and administration in their practices and regarding knowledge of indications and contraindications to influenza vaccination in pregnancy. RESULTS: Of the 20 obstetricians and 66 family physicians completing the survey, 68.4% of obstetricians and 90.5% of family physicians carried the vaccine in their offices (P =.027). Both obstetricians and family physicians incorrectly perceived multiple factors as contraindications to influenza vaccination in pregnancy. Obstetricians and family physicians reported similar proportions of their pregnant patients received the vaccine (35 versus 40%). CONCLUSIONS: In this study, more family physicians had the influenza vaccine available than obstetricians, but there was no difference in estimated rates of vaccination during pregnancy or in the understanding of its indications and contraindications. Finally, no physicians in our community reported providing influenza vaccination in pregnancy at recommended frequencies. Further research is needed to clarify methods of improving vaccination rates in both family practice and obstetric settings.

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