Many prescriptions for acute sinusitis do not follow guidelines
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Key takeaways:
- More than half of antibiotic prescriptions for sinusitis follow guidelines, but nearly one-third do not.
- People in rural settings are more likely to receive improper antibiotic prescriptions.
More than half of antibiotic prescriptions for acute sinusitis follow prescribing guidelines, but nearly one-third do not, and most prescriptions are given for too long a duration, according to a study.
“Our study shows that opportunities to optimize antibiotic prescribing still exists, especially related to unnecessary prescribing and duration of therapy for acute sinusitis in adults,” Axel A. Vazquez-Deida, PharmD, MPH, BCIDP, a health scientist in the CDC’s Epidemic Intelligence Service, told Healio.
Research has shown that shorter durations of antibiotic therapy are just as effective as longer courses for many infections, and testing people with suspected sinusitis for specific bacteria could help to reduce some unnecessary prescriptions.
Vazques-Deida and colleagues analyzed administrative claims data on nearly 4.7 million sinusitis encounters among adults aged 18 to 64 years collected between Jan. 1, 2016, and Dec. 31, 2020. They classified first-line and second-line antibiotic agents and less than 7-day durations as being concordant with clinical practice guidelines.
Among the 4.7 million encounters, they found that 53% of patients received a guideline-concordant agent and 30% a guideline-discordant agent. The other 17% received no antibiotics.
Roughly 75% of first-line antibiotics and 63% of second-line antibiotics were prescribed for more than 7 days, exceeding recommendations.
Additionally, adults in rural areas were less likely to receive a guideline-concordant antibiotic for a proper duration, and urgent care encounters were less likely to result in concordant prescriptions than visits in the office setting, the researchers found
We asked Vazquez-Deida why these disparities exist and how they can be fixed.
Healio: What makes up the one-third of prescriptions that are guidance discordant?
Vazquez Deida: Most of the antibiotic prescriptions not recommended by professional society guidelines for acute sinusitis were macrolides and cephalosporins.
Clinical guidelines do not recommend the use of macrolides, such as azithromycin and clarithromycin, for acute sinusitis because of the high prevalence of macrolide-resistant Streptococcus pneumoniae, which is one of the most common respiratory pathogens that causes sinusitis. Despite this, macrolides were the second most frequently prescribed antibiotic class, accounting for about 22% of all prescriptions.
Oral cephalosporins, such as cefdinir, are also no longer recommended due to considerable variability in their activity against S. pneumoniae and Haemophilus infuenzae. We found that oral cephalosporins accounted for about 11% of all prescriptions.
Healio: Why are so many unnecessary antibiotic prescriptions given in the ED?
Vazquez Deida: In our study, 43% of ED visits for acute sinusitis led to an antibiotic prescription compared with 85% of urgent care visits and 83% of all sinusitis visits. Although the ED had less antibiotic prescribing for acute sinusitis, opportunities to improve antibiotic prescribing still exists. Because most cases of acute sinusitis have a viral etiology, antibiotics are often not warranted, and tailoring antibiotic stewardship intervention to different health care settings is important. For example, clinical decision-making support tools embedded in electronic health records for common infections managed in the outpatient setting can be implemented to improve antibiotic use.
Healio: Why do more people aged 18 to 24 years receive unnecessary prescriptions than people aged 25 to 64 years?
Vazquez Deida: Antibiotic treatment was more likely to be for the recommended duration for people 25 to 64 years compared with people aged 18 to 24 years. Because sinusitis is more common among adults aged 45 years and older, it is possible that younger adults might be managed differently, either because they seek care at different settings or might be seen by different types or specialties of prescribers than the ones who care for other age groups. These findings need to be further evaluated.
Healio: What is the main takeaway from the study for clinicians?
Vazquez Deida: Although two-thirds of prescriptions were for an antibiotic recommended by guidelines, 75% of these prescriptions were for more than 7 days, which is longer than recommended. This finding highlights a need to tailor antibiotic stewardship initiatives to support clinicians to optimize prescribing for the shortest, most effective duration of therapy.
We also found that patients receiving care for acute sinusitis in rural areas and urgent care settings were more likely to receive an antibiotic that exceeded the recommended duration. Clinicians and health care facilities could follow the CDC’s Core Elements of Outpatient Antibiotic Stewardship to optimize antibiotic agent selection and treatment duration for adults with acute sinusitis, especially in rural areas and urgent-care settings. Delayed prescribing and watchful waiting are strategies that may help ensure that antibiotics are prescribed only when needed for acute sinusitis.
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