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Table.  Antibiotics Prescribed for Acute Sinusitis in US Adults by Duration of Course
Antibiotics Prescribed for Acute Sinusitis in US Adults by Duration of Course
1.
Fleming-Dutra  KE, Hersh  AL, Shapiro  DJ,  et al.  Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011.  JAMA. 2016;315(17):1864-1873.PubMedGoogle ScholarCrossref
2.
Hersh  AL, Fleming-Dutra  KE, Shapiro  DJ, Hyun  DY, Hicks  LA; Outpatient Antibiotic Use Target-Setting Workgroup.  Frequency of first-line antibiotic selection among US ambulatory care visits for otitis media, sinusitis, and pharyngitis.  JAMA Intern Med. 2016;176(12):1870-1872.PubMedGoogle ScholarCrossref
3.
Chow  AW, Benninger  MS, Brook  I,  et al; Infectious Diseases Society of America.  IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults.  Clin Infect Dis. 2012;54(8):e72-e112.PubMedGoogle ScholarCrossref
4.
Piccirillo  JF, Mager  DE, Frisse  ME, Brophy  RH, Goggin  A.  Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis.  JAMA. 2001;286(15):1849-1856.PubMedGoogle ScholarCrossref
5.
Falagas  ME, Karageorgopoulos  DE, Grammatikos  AP, Matthaiou  DK.  Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials.  Br J Clin Pharmacol. 2009;67(2):161-171.PubMedGoogle ScholarCrossref
6.
Kucers  A, Crowe  S, Grayson  M, Hoy  J.  The Use of Antibiotics: A Clinical Review of Antibacterial, Antifungal and Antiviral Drugs. 5th ed. Oxford, England: Butterworth-Heinemann Publishers; 1997.
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    Research Letter
    Less Is More
    July 2018

    Antibiotic Therapy Duration in US Adults With Sinusitis

    Author Affiliations
    • 1Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
    JAMA Intern Med. 2018;178(7):992-994. doi:10.1001/jamainternmed.2018.0407

    Sinusitis is the most common condition for which outpatient antibiotic therapy is prescribed in the United States.1 Sinusitis antibiotic stewardship efforts have largely focused on whether to prescribe antibiotics and on the selection of appropriate antibiotics.1,2 When antibiotics are indicated for the treatment of acute bacterial sinusitis, the Infectious Diseases Society of America evidence-based clinical practice guidelines recommend 5 to 7 days of therapy for patients with a low risk of antibiotic resistance who have a favorable response to initial therapy.3 Guideline-concordant treatment duration may represent a stewardship opportunity. Our objective was to describe the duration of antibiotic therapy for acute sinusitis in adult outpatients.

    Methods

    We identified visits to physicians at which antibiotics were prescribed for sinusitis diagnoses in the 2016 National Disease and Therapeutic Index (IQVIA). The National Disease and Therapeutic Index is a 2-stage stratified cluster sample of drug therapies that is based on a random sample of US office-based physicians in private practice who report on all patient contacts for 2 randomly selected consecutive workdays. We included observations for visits by adults (≥18 years of age) to family practice, general practice, geriatrics, internal medicine, pediatrics, and emergency medicine physicians at which a new prescription for an oral antibiotic was given in association with an acute sinusitis diagnosis. We excluded visits associated with a diagnosis of chronic sinusitis, concurrent antibiotic prescriptions for other conditions, or missing data on duration of therapy. We generated estimates that accounted for the complex sample design with use of weighted analyses. We grouped antibiotics as penicillins (including amoxicillin-clavulanate), tetracyclines, fluoroquinolones, cephalosporins, azithromycin, or other. We categorized azithromycin separately because of its unique pharmacokinetic characteristics. We conducted a sensitivity analysis that included cases of unspecified as well as acute sinusitis. Statistical tests were conducted at the α = .05 level. We conducted all analyses using SAS, version 9.4 (SAS Institute Inc). The human subjects advisor from the National Center for Emerging and Zoonotic Infectious Diseases has determined that these data do not require institutional review board review.

    Results

    There were an estimated 3 696 976 visits (95% CI, 3 124 279-4 269 673) at which antibiotic therapy was prescribed for sinusitis that met our inclusion criteria. The median duration of therapy was 10.0 days (interquartile range, 7.0-10.0 days), and 69.6% (95% CI, 63.7%-75.4%) of therapies were prescribed for 10 days or longer (Table). When azithromycin prescriptions were excluded, 91.5% of antibiotic courses (95% CI, 87.8%-95.2%) were 10 days or longer, 7.6% (95% CI, 4.1%-11.1%) were 7 days, and 0.5% (95% CI, 0.0%-1.6%) were 5 days.

    Discussion

    More than two-thirds of antibiotic courses and 91% of nonazithromycin antibiotic courses prescribed for the treatment of acute sinusitis in adults were 10 days or longer, even though the Infectious Diseases Society of America recommends 5 to 7 days of therapy for uncomplicated cases.3 Notably, no penicillin or tetracycline prescriptions were for 5-day courses, and only 5% of antibiotic prescriptions were for 7-day courses of penicillins, tetracyclines, or fluoroquinolones. Although 7- to 10-day courses are recommended for patients at high risk or who have experienced failure of initial treatment,3 it is unlikely that such cases represent most patients in our study. Earlier work has shown that 90% of patients with sinusitis that is treated with antibiotics do not require additional antibiotic therapy.4 Shorter durations (3-7 days) of antibiotic therapy for sinusitis have been associated with similar outcomes and fewer drug-related adverse events compared with longer durations (6-10 days).5

    Greater than 20% of prescriptions were for a 5-day course of azithromycin, a course that clinicians and patients often find convenient. However, the Infectious Diseases Society of America explicitly recommends against the use of azithromycin for the treatment of sinusitis because of its known association with the development of drug resistance.3 In addition, because of high and persistent concentrations of azithromycin in tissue, 5 days of azithromycin therapy approximates 10 days of erythromycin therapy; therefore, a shorter course of treatment with azithromycin does not involve a shorter duration of antibiotic exposure.6

    Our study has limitations. First, we were not able to account for underlying conditions or other indicators for longer courses of antibiotic therapy. Second, by excluding visits with a diagnosis of unspecified sinusitis from our analysis, we may have excluded some cases of acute sinusitis. However, the findings of a sensitivity analysis that included cases of both acute and unspecified sinusitis were similar (median duration of therapy, 10.0 days; 88.1% [95% CI, 85.1%-91.0%] of nonazithromycin antibiotic courses were 10 days or longer in duration).

    Outpatient antibiotic stewardship programs can optimize infection management by ensuring guideline-concordant treatment, including the use of minimum effective durations of antibiotic therapy. The durations of most courses of antibiotic therapy for adult outpatients with sinusitis exceed guideline recommendations, which represents an opportunity to reduce the unnecessary use of antibiotics when therapy with antibiotics is indicated.

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    Article Information

    Accepted for Publication: January 20, 2018.

    Corresponding Author: Laura M. King, MPH, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS A-31, Atlanta, GA 30333 (lfq0@cdc.gov).

    Published Online: March 26, 2018. doi:10.1001/jamainternmed.2018.0407

    Author Contributions: Ms King had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: King, Sanchez, Hicks, Fleming-Dutra.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: King, Sanchez.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: King, Sanchez, Bartoces, Fleming-Dutra.

    Administrative, technical, or material support: Sanchez, Hicks, Fleming-Dutra.

    Study supervision: Hicks, Fleming-Dutra.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This work was supported by the Centers for Disease Control and Prevention.

    Role of the Funder/Sponsor: The Centers for Disease Control and Prevention participated in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

    References
    1.
    Fleming-Dutra  KE, Hersh  AL, Shapiro  DJ,  et al.  Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011.  JAMA. 2016;315(17):1864-1873.PubMedGoogle ScholarCrossref
    2.
    Hersh  AL, Fleming-Dutra  KE, Shapiro  DJ, Hyun  DY, Hicks  LA; Outpatient Antibiotic Use Target-Setting Workgroup.  Frequency of first-line antibiotic selection among US ambulatory care visits for otitis media, sinusitis, and pharyngitis.  JAMA Intern Med. 2016;176(12):1870-1872.PubMedGoogle ScholarCrossref
    3.
    Chow  AW, Benninger  MS, Brook  I,  et al; Infectious Diseases Society of America.  IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults.  Clin Infect Dis. 2012;54(8):e72-e112.PubMedGoogle ScholarCrossref
    4.
    Piccirillo  JF, Mager  DE, Frisse  ME, Brophy  RH, Goggin  A.  Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis.  JAMA. 2001;286(15):1849-1856.PubMedGoogle ScholarCrossref
    5.
    Falagas  ME, Karageorgopoulos  DE, Grammatikos  AP, Matthaiou  DK.  Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials.  Br J Clin Pharmacol. 2009;67(2):161-171.PubMedGoogle ScholarCrossref
    6.
    Kucers  A, Crowe  S, Grayson  M, Hoy  J.  The Use of Antibiotics: A Clinical Review of Antibacterial, Antifungal and Antiviral Drugs. 5th ed. Oxford, England: Butterworth-Heinemann Publishers; 1997.
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