When is it appropriate to withhold empirical antibiotics in patients with suspected infections, considering factors such as underlying health conditions (e.g. chronic obstructive pulmonary disease (COPD) or heart disease), immune function, and symptom severity (e.g. high fever, difficulty breathing, or signs of sepsis)?

When to Withhold Empirical Antibiotics

Withhold empirical antibiotics in patients with lower respiratory tract infections without clinical suspicion of pneumonia, non-severe COPD exacerbations with low suspicion of bacterial pneumonia, and uncomplicated diverticulitis in immunocompetent patients. 1

Clear Indications to Withhold Antibiotics

Lower Respiratory Tract Infections (LRTI)

• Strongly recommend withholding antibiotics in patients presenting with LRTI when there is no clinical suspicion of pneumonia (strong recommendation, moderate certainty) 1
• This applies to acute bronchitis, which is predominantly viral and self-limiting 2, 3
• Evidence shows that withholding antibiotics in LRTI without pneumonia reduces antibiotic consumption by 75% without worsening clinical outcomes 1
• Patients must receive clear instructions on self-monitoring and when to return if symptoms worsen 1

COPD Exacerbations

• Withhold antibiotics in non-severe acute exacerbations of COPD when there is low suspicion of bacterial pneumonia (weak recommendation, very low certainty) 1
• This applies specifically to patients without increased sputum purulence combined with worsening dyspnea or increased sputum volume 1
• Studies demonstrate a 34-44% reduction in antibiotic use without increased mortality or hospitalization 1
• Patients with severe COPD, advanced structural lung disease, or recent hospitalization should not have antibiotics withheld 1

Uncomplicated Diverticulitis

• Strongly recommend withholding antibiotics in immunocompetent patients with uncomplicated diverticulitis (strong recommendation, moderate certainty) 1
• This applies only to patients without signs of perforation, abscess, or systemic toxicity 1

When Antibiotics MUST Be Given (Do Not Withhold)

High-Risk Clinical Scenarios

• Critically ill patients admitted to ICU with suspected infection require immediate empirical antibiotics after obtaining cultures 1
• Patients with septic shock or organ dysfunction warrant immediate treatment 1
• Severe community-acquired pneumonia (PSI score IV-V or ICU criteria) requires antibiotics without delay 1

Immunocompromised Patients

• Never withhold antibiotics in immunocompromised patients with suspected bacterial infections, including those receiving chemotherapy, organ transplant recipients, HIV with low CD4 counts, or prolonged corticosteroid use 1
• These patients can deteriorate rapidly with untreated bacterial infections 1

Specific Infections

• Do not withhold antibiotics in cystitis (weak recommendation against withholding, moderate certainty) 1
• Cellulitis/erysipelas requires antibiotics, though blood cultures are not routinely needed unless the patient is immunocompromised or has prosthetic devices 1

Clinical Assessment Framework

Key Discriminating Features for Bacterial Infection

• Radiological findings consistent with bacterial pneumonia on chest imaging 1
• Inflammatory markers: Consider bacterial infection when CRP is elevated with clinical correlation, though procalcitonin alone should not drive decisions in COVID-19 or respiratory infections 1
• Sputum purulence combined with increased dyspnea and/or increased sputum volume in COPD patients 1
• Systemic symptoms: High fever, rigors, hemodynamic instability 1

Obtain Cultures Before Deciding

• Blood cultures should be obtained before withholding antibiotics in patients with systemic symptoms, immunocompromised state, or risk factors for resistant pathogens 1
• Sputum and urine cultures help support or refute bacterial infection diagnosis 1
• Urinary pneumococcal antigen testing can guide decisions in respiratory infections 1

Common Pitfalls to Avoid

Patient Selection Errors

• Do not apply "watchful waiting" strategies to elderly or debilitated patients with respiratory symptoms 4
• Patients with significant underlying health problems (functional asplenia, immunodeficiency) should not have antibiotics withheld even for mild symptoms 4
• Do not withhold antibiotics in patients with known bacteremia or requiring hospitalization 4

Safety Net Requirements

• All patients discharged without antibiotics must receive explicit instructions on warning signs and when to return 1
• Implement structured culture follow-up programs to identify patients who develop bacterial infections after initial discharge 1
• Consider delayed prescription strategies (prescription to fill only if symptoms persist beyond 3-7 days) for selected LRTI patients, which reduces antibiotic use by 45-70% 1

Documentation Requirements

• Document specific reasons for withholding antibiotics, including absence of pneumonia on imaging, lack of purulent sputum, or immunocompetent status 1
• Record patient education provided about return precautions 1

Special Populations

COVID-19 Patients

• Withhold antibiotics in COVID-19 patients with mild to moderate disease unless there is high clinical suspicion of bacterial co-infection 1
• Bacterial co-infection rates are low (typically <10%) in COVID-19 1
• Obtain cultures before starting antibiotics if bacterial infection is suspected 1

Patients with Chronic Conditions

• Heart disease alone does not mandate antibiotics for respiratory symptoms without evidence of bacterial infection 1
• COPD patients with non-severe exacerbations can safely avoid antibiotics when bacterial pneumonia is unlikely 1