Despite the existence of clear clinical criteria for the treatment of bacterial sinusitis, primary care clinicians were found to not follow Infectious Disease Society of America (IDSA) clinical practice guidelines with regard to prescribing and frequently overprescribed antibiotics, according to the results of a retrospective chart review published in Clinical Infectious Diseases.
Researchers used data from the Northwestern Medicine Enterprise Data Warehouse, a joint initiative of the Northwestern University Feinberg School of Medicine and Northwestern Memorial Health Care, comprising information on 6.6 million patients. Between January 2017 and December 2017, 2452 distinct visits by adult patients with acute sinusitis were documented.
Criteria for appropriate antibiotic prescribing for sinusitis include the presence of persistent, severe, or worsening symptom. Persistent symptoms were defined as sinusitis for ≥10 days and not improving; severe symptoms included a fever >102°F and purulent nasal discharge or facial pain lasting more than 3 to 4 days at the beginning of illness; and worsening symptoms involved new fever, headache, or increase in nasal discharge following an upper respiratory tract infection that lasted 5 to 6 days and was initially improving. The researchers noted that their inclusion criteria were very specific, and their “assessment of guideline-concordant antibiotic-appropriateness was very forgiving.” In addition, any mention of worsening symptoms was considered to fulfill the criteria; therefore, the findings of this study represent an upper bound of appropriateness.
Of the 2452 distinct visits, data for 500 patients who met at least one or any combination of criteria for antibiotic prescribing described earlier were randomly selected for the chart review; 425 met all inclusion criteria, 50% of whom met criteria for antibiotic prescribing. Persistent symptoms (77%) represented the most frequently reported symptom criteria for antibiotic prescribing.
Although only half of the patients with acute sinusitis met criteria for antibiotic prescribing, actual antibiotic prescribing rates were significantly higher. Clinicians prescribed antibiotics at 205 (96%) of the 214 visits that met symptom criteria and in 193 (92%) of the 211 visits that did not meet criteria (P =.07).
In addition, antibiotic selection was not guideline-concordant. The IDSA guidelines recommend amoxicillin-clavulanate or amoxicillin as first-line antibiotics for the treatment of bacterial sinusitis; these agents made up 46% and 12% of antibiotic prescriptions, respectively. Although the guidelines specifically recommend against the use of macrolides and third-generation cephalosporins for acute sinusitis, azithromycin and cefdinir were also prescribed (20% and 6%, respectively).
“To meaningfully reduce inappropriate antibiotic prescribing, future stewardship efforts should address the diagnosis of and appropriateness of antibiotic prescribing for sinusitis,” concluded the researchers.
Truitt KN, Brown T, Lee JY, Linder JA. Appropriateness of antibiotic prescribing for acute sinusitis in primary care: a cross-sectional study [published online June 8, 2020]. Clin Infect Dis. doi:10.1093/cid/ciaa736