Improving care for acute respiratory infections: better systems, not better microbiology.

Americans made 1.17 billion visits to ambulatory clinics and emergency departments in 2005. Acute respiratory infections (i.e., nonspecific upper respiratory infections, otitis media, sinusitis, phar-yngitis, bronchitis, influenza, and pneumonia) account for 11% of this total (130 million visits). This makes acute respiratory infections the most common symptomatic reason for seeking medical care in the United States. It is interesting that, despite the prevalence and impact of such infections on the health care system, no medical or scientific discipline seems to have taken " ownership " of acute respiratory infections. Acute respiratory infections should fall somewhere at the intersection of otolaryngology, pulmonary, and infectious diseases; alas, one doesn't perform surgery, bronchoscopy, or culture for most acute respiratory infections. Seventy percent of visits for acute respiratory infections are made to primary care physicians. In addition to the fact that there is no National Institute of Primary Care, the lack of interest in acute respiratory infections might also be attributable to the self-limited nature of and low morbidity associated with these infections. The vast majority of acute respiratory infections only make people miserable for a few days to a few weeks. However, among the millions of acute respiratory infections are cases due to potentially more-morbid conditions that can be treated with antimi-crobial drugs, such as pneumonia, strep-tococcal pharyngitis, and influenza. Influenza itself can range in severity from mild illness to life-threatening disease. In the United States, influenza causes millions of clinic visits, hundreds of thousands of hospitalizations, and tens of thousands of deaths each year. Vaccination with the influenza vaccine remains the best means of reducing the incidence and severity of and complications from influenza. For those individuals who contract influenza, either because they were not vaccinated or despite vaccination, anti-influenza antiviral medications can shorten the course of influenza and reduce complications. Anti-influenza antiviral medications are cost-effective. Despite their effectiveness, the proper use of anti-influenza antiviral medications is challenging. Patients need to recognize that they might have influenza, access the medical system, and want to take, have access to, and be able to afford antiviral drugs. Clinicians need to recognize the possibility of influenza, consider whether testing will be helpful, perhaps perform testing, and consider whether antiviral drugs—medication that individual providers do not often prescribe—will be helpful. All of this needs to happen within 48 h after the onset of symptoms. The rate-limiting step is patients' accessing of the medical system; patients generally …