Despite concordance with guidelines, antibiotics given for acute sinusitis in kids may still be longer than necessary, leading to excess antibiotic exposure.
“Acute sinusitis is the diagnosis associated with the highest rate of antibiotic prescribing among children in the outpatient setting,” Timothy J. Savage, MD, MPH, MSc, notes. “While we know a substantial number of these patients are likely infected with a virus, and thus would not benefit from an antibiotic, understanding which antibiotics are prescribed, and for what duration, is essential to ensure the best quality care is provided and identify areas for antimicrobial stewardship interventions.”
For a study published in Pediatrics, Dr. Savage and colleagues aimed to determine the impact of two sets of evidence-based guidelines on the management of acute sinusitis, one from the Infectious Diseases Society of America and one from the American Academy of Pediatrics, including the type of antibiotic prescribed and the duration.
“We identified a cohort of more than three million children from a nationwide healthcare utilization database, spanning encounters from 2003 through 2020,” Dr. Savage explains. “We reported the proportion of patients dispensed a given antibiotic, including how many days’ supply they were dispensed. We then performed an interrupted time series analysis to determine if the publication of the IDSA guidelines changed which antibiotics were being prescribed.”
Prescriptions of 10 or More Days ‘May Be Unnecessary’
The final cohort included 3.75 million patients with eligible acute sinusitis diagnoses, 84.9% of which were prescribed an antibiotic. The median age was 9 (interquartile range, 4-14) and the most commonly prescribed antibiotic was amoxicillin (36%).
“As of 2020, 65% of children are prescribed a first-line antibiotic, either amoxicillin or amoxicillin-clavulanate,” Dr. Savage says. “While that indicates pretty good concordance with evidence-based guidelines, it means that a significant number of patients are prescribed an antibiotic that is likely excessively broad, most often azithromycin and cefdinir, which can contribute to higher rates of adverse events and antimicrobial resistance.”
Almost all children—94%—received an antibiotic prescription for 10 or more days.
“While this is what the guidelines recommend (10-14 days), it may be longer than necessary, as many recent studies have found that a shorter duration treatment of bacterial infections is non-inferior to longer treatment,” Dr. Savage says. “The IDSA guidelines had both immediate and lasting impacts on prescribing patterns, leading to the increased use of guideline-concordant antibiotics and a corresponding decrease in the use of non-guideline concordant antibiotics. This emphasizes that evidence-based guidelines can and do impact care.”
Improving Antimicrobial Stewardship & Diagnostic Tools
The findings indicate that “35% of kids are still prescribed a non-first line, excessively broad antibiotic as initial treatment of acute bacterial sinusitis,” according to Dr. Savage.
“This is an opportunity for antimicrobial stewardship efforts to reduce unnecessary antibiotic exposure, which can bring down the number of antibiotic-associated adverse events and slow the advancement of antibiotic resistance,” he continues. “Recent AAP guidance indicates that 5-7 days may be enough treatment for acute bacterial sinusitis in kids. Our study shows that 94% of kids are prescribed 10 days or more. If this bears out to be true, 14.7 to 24.4 million days of antibiotic exposure could be avoided if all kids are prescribed a shorter course treatment.”
Future research should first identify “better diagnostic tools to attempt to discern when acute sinusitis is due to a viral infection versus a bacterial infection to guide when we should be using antibiotics,” Dr. Savage says.
“Then, we need rigorous studies of patients treated with antibiotics to compare the effectiveness and safety of current first-line antibiotics, including amoxicillin and amoxicillin-clavulanate, to help clinicians decide which antibiotic to start with. We also need rigorous studies to compare short to long durations of treatment. We are working on answering some of these important questions next.”
