Most sinusitis prescriptions exceed recommended duration, study finds

More than two-thirds of antibiotic courses and 92% of nonazithromycin antibiotic courses prescribed for acute sinusitis in adults were 10 days or longer, despite recommendations of five to seven days for uncomplicated cases, a study found.

To describe the duration of antibiotic therapy for acute sinusitis, researchers used the 2016 National Disease and Therapeutic Index, a two-stage stratified cluster sample of drug therapies that is based on a random sample of U.S. office-based physicians in private practice who report on all patient contacts for two randomly selected consecutive workdays.

Researchers included visits by adults 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. They excluded visits associated with a diagnosis of chronic sinusitis, concurrent antibiotic prescriptions for other conditions, or missing data on duration of therapy. Antibiotics were grouped as penicillins (including amoxicillin-clavulanate), tetracyclines, fluoroquinolones, cephalosporins, azithromycin, or other. Azithromycin was categorized separately because of its unique pharmacokinetic characteristics. Results were published in a research letter in JAMA Internal Medicine on March 26.

There were an estimated 3.7 million visits at which antibiotics were prescribed for sinusitis. The median duration of therapy was 10.0 days (interquartile range, 7.0 to 10.0 days), and 69.6% (95% CI, 63.7% to 75.4%) of prescriptions were for 10 days or longer. When azithromycin prescriptions were excluded, 91.5% of antibiotic courses (95% CI, 87.8% to 95.2%) were for 10 days or longer, 7.6% (95% CI, 4.1% to 11.1%) were for seven days, and 0.5% (95% CI, 0.0% to 1.6%) were for five days.

Researchers noted that more than 20% of prescriptions were for a five-day course of azithromycin, a course that clinicians and patients often find convenient but that the Infectious Diseases Society of America explicitly recommends against because of its known association with the development of drug resistance. Because of high and persistent concentrations of azithromycin in tissue, five 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, the researchers noted.

“Outpatient antibiotic stewardship programs can optimize infection management by ensuring guideline-concordant treatment, including the use of minimum effective durations of antibiotic therapy,” the authors wrote. “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.”

An unrelated study recently found that antibiotic resistance added $1,383 to the cost of treating a patient with a bacterial infection in the U.S. in 2014, amounting to a national treatment cost of approximately $2.2 billion.

The authors analyzed data from the Medical Expenditure Panel Survey for the years 2002 through 2014 and estimated the incremental health care costs of treating a resistant infection. While the number of bacterial infections remained relatively constant, totaling 13.5 million in 2002 and 14.3 million in 2014, the share of these infections that were antibiotic resistant rose from 5.2% to 11.0% in the same period.

This study, which was supported by Merck and Co., appeared in the April Health Affairs. “An important feature of this study is that it shows that the vast majority of patients with antibiotic-resistant infections are not given the appropriate ICD-9-CM diagnosis codes,” the authors concluded. “This underuse of codes makes it difficult to detect the infections and … uncover the infections' true prevalence and burden.”