Respiratory tract infections such as viral upper respiratory tract infections, sinusitis or acute bronchitis account for the majority of unnecessary antibiotic prescriptions (Shapiro 2014). This nomination seeks to clarify the benefit of symptomatic relief recommendations for common respiratory infections to provide clinician guidance for adjuvant or alternative therapies to antibiotics. Our nomination is for the following question: What over-the-counter medications or complementary and alternative medicines provide the clearest benefit of symptom resolution for common acute respiratory infections such as sinusitis, pharyngitis, bronchitis, otitis media, or the common cold?

Antibiotic use is the single most important factor contributing to antibiotic resistance. Up to half of antibiotic use among outpatients in the United States is inappropriate, and at least thirty percent of prescriptions provide no therapeutic benefit (Fleming-Dutra 2016). It is estimated that one in five adverse drug events in the United States is due to an antibiotic, accounting for over 142,000 emergency room visits annually (Shehab 2008). Clarifying and updating evidence-based recommendations for symptomatic relief for acute respiratory tract infection can better enable clinicians to make choices consistent with appropriate antibiotic use. Often prescribers give antibiotics because there are no other straightforward alternatives to antibiotic treatment, or evidence-based symptomatic treatment is unclear. The National Strategy for Combatting Antibiotic Resistance released in 2015 calls for a 50% reduction in unnecessary antibiotic prescriptions (http://www.cdc.gov/drugresistance/federal-engagement-in-ar/national-

strategy/index.html) ( National Strategy ), and this topic can greatly contribute to this effort. There are few systematic reviews available examining symptomatic relief for respiratory tract infections, which presents AHRQ an opportunity to fill in this gap of knowledge.

Qualitative research suggests that knowledge deficits do not entirely account for injudicious antibiotic prescribing. Often clinicians are subject to psychosocial pressures from patients to do something about a patient illness, which is often interpreted as providing an antibiotic prescription (Sanchez 2014). However, this clinician perception inadvertently results in unnecessary antibiotic prescriptions.Clarification of the current literature on comparative effectiveness of available symptomatic therapies for respiratory tract infections will better assist clinicians in abstaining from antibiotic prescribing when antibiotics do not provide a clear benefit, and providing meaningful treatment alternatives for common infections. Providing evidence-based non-antibiotic recommendations for management of respiratory tract infections will optimize patient outcomes by minimizing unnecessary exposure to antibiotics, and by extension, potentially serious adverse drug effects such as Clostridium difficile infections, which account for an estimated 29000 deaths annually (Lessa 2015).

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