Clinical Evidence and Biomarkers Linking Allergy and Acute or Chronic Rhinosinusitis in Children: a Systematic Review

Purpose of the Review

We provide a systematic review of experimental and clinical evidences linking allergy to acute, including common cold, and chronic rhinosinusitis in children. Furthermore, we questioned if anti-allergy treatment may prevent the occurrence of rhinosinusitis or improve outcomes of its specific management.

Recent Findings

Allergic rhinitis is a common childhood disease in industrialized countries that is responsible for a major impact on quality of life and healthcare resources. Over the years many authors tried to correlate allergy with comorbidities and in particular to the onset of rhinosinusitis including common cold, even though conflicting results are frequently reached. We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) process. Our search yielded 7103 that were finally screened. This resulted in 25 publications of which the full texts were assessed and included in a qualitative analysis per different phenotypes of rhinosinusitis.

Summary

The evidence suggests that allergy may lead to overall impairment of mechanical and immunological defense function of the nasal mucosa against viruses and that anti-allergy treatment may significantly decrease the number and severity of upper respiratory tract infections including common colds in children. It was not possible to perform the analysis for allergy and post-viral acute rhinosinusitis, bacterial acute rhinosinusitis, and recurrent acute rhinosinusitis because of paucity and heterogeneity of data. Although there is no definitive proof of causation linking allergy to chronic rhinosinusitis, studies lead to suppose that anti-allergy treatment may improve outcomes of specific CRS treatments.

Reducing Antibiotic Prescribing in Primary Care for Respiratory Illness

BACKGROUND

One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits.

METHODS

In this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to <11 years old without recent antibiotic use were included. Clinicians received the intervention as 3 program modules containing online tutorials and webinars on evidence-based communication strategies and antibioti c prescribing, booster video vignettes, and individualized antibiotic prescribing feedback reports over 11 months. The primary outcome was overall antibiotic prescribing rates for all ARTI visits. Mixed-effects logistic regression compared prescribing rates during each program module and a postintervention period to a baseline control period. Odds ratios were converted to adjusted rate ratios (aRRs) for interpretability.

RESULTS

Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90-0.96). Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50-0.87) and sinusitis (aRR 0.59; 95% CI, 0.44-0.77) but not for acute otitis media (aRR 0.93; 95% CI, 0.83-1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95% CI, 0.51-0.70).

CONCLUSIONS

This program reduced antibiotic prescribing during outpatient ARTI visits; broader dissemination may be beneficial.

[Optimization of treatment of patients with acute bacterial rhinosinusitis with relating allergic rhinitis]

The article considers the problem of acute rhinosinusitis and its multifactorial relationship with allergic rhinitis. Data on a higher incidence of acute rhinosinusitis in patients with an allergic background is given, which is primarily associated with a deterioration in the state of the respiratory tract mucous membrane barrier function. It is shown that local allergic inflammation causes a more severe course of acute rhinosinusitis. A review of the combined course of these pathological processes is carried out and options for their treatment are considered. A study of the clinical use of the complex preparation Frinosol is described, which, thanks to the combination of a nasal decongestant and an antihistamine in its composition, effectively alleviates the symptoms of acute rhinosinusitis in patients with allergic rhinitis. It has been shown that the use of Frinosol in the complex treatment of adult patients with acute bacterial rhinosinusitis, combined with allergic rhinitis is safe and effective.

Increasing paediatric prescribing rates in British Columbian children: cause for concern?

OBJECTIVES

Antibiotic prescribing in paediatric care is highly prevalent, and quite often, children are prescribed for conditions, like upper respiratory tract infections, which are self-limiting and viral in aetiology. The purpose of this study was to identify potential new targets for provincial antimicrobial stewardship efforts.

METHODS

Antibiotic prescription data for children were extracted from a provincial prescription database, linked to physician billing data in order to obtain diagnostic information, and then combined with demographic data in order to obtain patient age, sex and geographic location. Prescription rates were calculated, and trends were examined by major anatomical therapeutic chemical (ATC) classification.

RESULTS

Our cohort included an average of 271,134 children per year and 1,767,652 antibiotic prescriptions. Antibiotic utilization increased 4.5% (from 453 to 474 prescriptions per 1000 population). The greatest increases in prescribing were seen in children aged 0-2 years. Increased indication-specific rates of prescribing were observed in children aged 0-2 years, across every category. Although antibiotic use for upper respiratory tract infections decreased, prescribing rates remain as high as 5 times more than other indications.

CONCLUSION

Past studies have widely illustrated decreasing or static rates of prescribing in British Columbia. However, these results signal a potential problem in the sphere of paediatric antibiotic prescribing, wherein rates have been increasing since 2013. Despite the success of provincial efforts in reducing the use of broad-spectrum penicillins, marked surges in the use of classes like tetracyclines, quinolones and other antibacterials identify a new potential target for provincial stewardship.

Assessment of antibiotic use and concordance with practice guidelines within 3 diverse ambulatory clinic systems

OBJECTIVES

The objectives of this study were (1) to determine the rate of antibiotic prescribing at ambulatory clinics, and (2) to assess the concordance of antibiotic prescriptions with published guidelines and Food and Drug Administration-approved indications in terms of drug choices and dosing regimen.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Patients of all ages receiving at least 1 prescription during ambulatory visits in 2016 to 2017 were observed.

OUTCOME MEASURES

For each of the 3 clinic systems included in this study, oral antibiotic prescribing rates were estimated per patient and per ambulatory visit. Then, the concordance of oral antibiotic prescribing was assessed with respect to (1) choice of agent and (2) the dosing regimen by comparing it to the recommended therapeutic regimen (RTR).

RESULTS

A total of 284,348 patients receiving at least 1 prescription were included in the analysis. Between clinics, 17.4 to 43.7 per 100 patients received antibiotics. Of the antibiotics prescribed, 48.9% in Clinic A, 48.0% in Clinic B, and 60.7% in Clinic C were considered to be discordant in terms of drug choice. When the dosing regimen was taken into account in addition to the choice of agent, 72.6% in Clinic A, 76.7% in Clinic B, and 81.6% in Clinic C were discordant based on drug choice or dosing regimen. Of the prescriptions written with a discordant dosing regimen, 91.2% in Clinic A, 79.6% in Clinic B, and 91.0% in Clinic C were at a higher dosage than RTR.

CONCLUSION

Antibiotic prescribing rates vary by clinics, whereas discordant prescribing is consistently prevalent across clinics. More efforts should be put into ambulatory care to address antibiotic misuse problems, and our method could improve ambulatory antimicrobial stewardship programs.

Temporal trends in ambulatory antibiotic prescription rates in South Carolina: Impact of age, gender, and resident location

OBJECTIVE

To examine the temporal trends in ambulatory antibiotic prescription fill rates and to determine the influences of age, gender, and location.

DESIGN

Population-based cohort study.

SETTING

Ambulatory setting in South Carolina.

PATIENTS

Patients ≤64 years of age from January 2012 to December 2017.

METHODS

Aggregated pharmacy claims data for oral antibiotic prescriptions were utilized to estimate community antibiotic prescription rates. Poisson regression or Student t tests were used to examine overall temporal trend in antibiotic prescription rates, seasonal variation, and the trends across age group, gender, and rural versus urban location.

RESULTS

Overall antibiotic prescription rates decrease from 1,127 to 897 per 1,000 person years (P < .001). The decrease was more noticeable in persons aged <18 years (26%) and 18-39 years (20%) than in those aged 40-64 years (5%; P < .001 for all). Prescription rates were higher among females than males in all age groups, although this finding was the most pronounced in group aged 18-39 years (1,232 vs 585 per 1,000 person years; P < .0001). Annualized antibiotic prescription rates were higher during the winter months (December-March) than the rest of the year (1,145 vs 885 per 1,000 person years; P < .0001), and rates were higher in rural areas than in urban areas (1,032 vs 941 per 1,000 person years; P < .0001).

CONCLUSIONS

The decline in ambulatory antibiotic prescription rates is encouraging. Ongoing ambulatory antibiotic stewardship efforts across South Carolina should focus on older adults, rural areas, and during the winter season when antibiotic prescriptions peak.

Common Cold and Acute Rhinosinusitis: Up-to-Date Management in 2020

PURPOSE OF REVIEW

The purposes of the review are as follows: (1) to define acute rhinosinusitis (ARS) and their phenotypes, (2) to highlight the ARS management according to international guidelines, (3) to compare the physicians' management with the ARS guideline recommendations, and (4) to report ARS socioeconomic burden.

RECENT FINDINGS

Bacterial and non-bacterial ARS have similar symptoms, although they can be discriminated by using a combination of specific signs and symptoms. The prescription of antibiotics should be limited to clearly suspected bacterial ARS. There is an overuse of diagnosis tools and treatment prescriptions. The total cost per ARS episode in Europe is over €1000. ARS is mainly an inflammatory disease triggered by viral infection, and few cases end up developing bacterial infection. In most of the cases, it is a self-resolving disease which diagnosis is mainly clinical and the treatment symptomatic. The incidence of complications is low and independent of antibiotic use. There is a high socioeconomic burden associated to ARS.

Outpatient fluoroquinolone prescribing patterns before and after US FDA boxed warning

OBJECTIVES

Fluoroquinolones are routinely overprescribed for uncomplicated urinary tract infection (uUTI), acute sinusitis, and acute bronchitis. In 2016, the United States (US) Food and Drug Administration (FDA) updated the boxed warning on fluoroquinolones, recommending against their use as first-line agents for the routine pharmacologic management of uUTI, acute sinusitis, and acute bronchitis in patients who have other treatment options. The primary objective of this study was to determine if the 2016 expanded boxed warning was associated with decreased fluoroquinolone prescription rates for these three diagnoses.

METHODS

We retrospectively reviewed antibiotics prescribed at a single, large, academic outpatient center for these three diagnoses between January 2013 and May 2018. Interrupted time series analysis was used to compare the rate of fluoroquinolone prescriptions before and after the May 2016 FDA boxed warning.

RESULTS

A total of 10 087 antibiotic prescriptions for these three diagnoses were examined. There was no significant change in fluoroquinolone prescription rates after the FDA boxed warning. The majority of inappropriate fluoroquinolone prescriptions were given for the management of uUTI.

CONCLUSION

The 2016 US FDA boxed warning against fluoroquinolone use for uUTI, acute sinusitis, and acute bronchitis was not associated with a statistically significant reduction in the rate of fluoroquinolone prescriptions for these diagnoses. Additional research is needed to define how US FDA boxed warnings may be incorporated into broader antibiotic stewardship programs to decrease overuse of fluoroquinolones and avoid adverse effects of the drug class, including Clostridioides difficile infections and emergence of resistant organisms.

Overcoming Multidrug Resistance and Biofilms of Pseudomonas aeruginosa with a Single Dual-Function Potentiator of β-Lactams

Clinicians prescribe hundreds of millions of β-lactam antibiotics to treat the majority of patients presenting with bacterial infections. Patient outcomes are positive unless resistant bacteria, such as Pseudomonas aeruginosa (P. aeruginosa), are present. P. aeruginosa has both intrinsic and acquired antibiotic resistance, making clinical management of infection a real challenge, particularly when these bacteria are sequestered in biofilms. These problems would be alleviated if, upon the initial presentation of bacterial infection symptoms, clinicians were able to administer an antibiotic that kills both susceptible and otherwise resistant bacteria and eradicates biofilms. As the most common class of antibiotics, β-lactams could be used in a new drug if the leading causes of β-lactam antibiotic resistance, permeation barriers from lipopolysaccharide, efflux pumps, and β-lactamase enzymes, were also defeated. Against P. aeruginosa and their biofilms, the potency of β-lactam antibiotics is restored with 600 Da branched polyethylenimine (600 Da BPEI). Checkerboard assays using microtiter plates demonstrate the potentiation of piperacillin, cefepime, Meropenem, and erythromycin antibiotics. Growth curves demonstrate that only a combination of 600 Da BPEI and piperacillin produces growth inhibition against antibiotic resistant P. aeruginosa. Scanning electron microscopy (SEM) was used to confirm that the combination treatment leads to abnormal P. aeruginosa morphology. Data collected with isothermal titration calorimetry and fluorescence spectroscopy demonstrate a mechanism of action in which potentiation at low concentrations of 600 Da BPEI reduces diffusion barriers from lipopolysaccharides without disrupting the outer membrane itself. Coupled with the ability to overcome a reduction in antibiotic activity created by biofilm exopolymers, targeting anionic sites on lipopolysaccharides and biofilm exopolysaccharides with the same compound provides new opportunities to counter the rise of multidrug-resistant infections.

Oral β-Lactam Antibiotics for Pediatric Otitis Media, Rhinosinusitis, and Pneumonia

Acute otitis media, acute bacterial rhinosinusitis, and community-acquired pneumonia are major drivers of pediatric antibiotic consumption. With many available options and the added challenges of navigating antibiotic allergies and de-escalating from intravenous treatment for children requiring hospitalization, prescribing for these relatively simple infections can be a source of confusion and error. The purpose of this article is to evaluate the pharmacokinetic and pharmacodynamic properties of antibiotics commonly prescribed for these disease states, and to specifically compare antipneumococcal activity between oral beta-lactams.

Quality Indicators for the Diagnosis and Management of Acute Bacterial Rhinosinusitis

Background

Acute bacterial rhinosinusitis (ABRS) is a highly prevalent disease that is treated by a variety of specialties, including but not limited to, family physicians, emergency physicians, otolaryngology—head and neck surgeons, infectious disease specialists, and allergy and immunologists. Unfortunately, despite high-quality guidelines, variable and substandard care continues to be demonstrated in the treatment of ABRS.

Objective

This study aimed to develop ABRS-specific quality indicators (QIs) to evaluate the diagnosis and management that reduces symptoms, improves quality of life, and prevents complications.

Methods

A guideline-based approach, proposed by Kötter et al., was used to develop QIs for ABRS. Candidate indicators (CIs) were extracted from 4 guiding documents and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND/University of California at Los Angeles appropriateness methodology.

Results

Twenty-nine CIs were identified after literature review and evaluated by our panel. Of these, 5 CIs reached consensus as being appropriate QIs, with 1 requiring additional discussion. After a second round of evaluations, the panel selected 7 QIs as appropriate measures of high-quality care.

Conclusion

This study proposes 7 QIs for the diagnosis and management of patients with ABRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay for performance initiatives.

Evaluation of clinicians' knowledge, attitudes, and planned behaviors related to an intervention to improve acute respiratory infection management

BACKGROUND

Acute respiratory tract infections (ARIs) are commonly diagnosed and major drivers of antibiotic prescribing. Clinician-focused interventions can reduce unnecessary antibiotic prescribing for ARIs. We elicited clinician feedback to design sustainable interventions to improve ARI management by understanding the mental framework of clinicians surrounding antibiotic prescribing within Veterans' Health Administration clinics.

METHODS

We conducted one-on-one interviews with clinicians (n = 20) from clinics targeted for intervention at 5 facilities. The theory of planned behavior guided interview questions. Interviews were audio recorded and transcribed for qualitative analysis. An iterative coding approach identified 6 themes.

RESULTS

Emergent themes: (1) barriers to appropriate prescribing are multifactorial and include challenges of behavior change; (2) antibiotic prescribing decisions are perceived as autonomous yet, diagnostic uncertainty and perceptions of patient demand can make prescribing decisions difficult; (3) clinicians perceive variation in peer prescribing practices and influences; (4) clinician-focused interventions are valuable if delivered with sensitivity; (5) communication strategies for educating patients are preferred to a shared decisions process; and (6) team standardization of practice and communication are key to facilitate appropriate prescribing. Clinicians perceived audit-and-feedback with peer comparison, academic detailing, and enhanced patient communication strategies as viable approaches to improving appropriate prescribing.

CONCLUSION

Implementation strategies that enable clinicians to overcome diagnostic uncertainty, perceived patient demand, and improve patient education are desired. Implementation strategies were welcomed, and some were more readily accepted (eg, audit feedback) than others (eg, shared decision making). Implementation strategies should address clinicians' perceptions of antibiotic prescribing practices and should enhance their patient communication skills.

Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review

BACKGROUND

Antibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes.

METHODS

A multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015-2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes.

RESULTS

Of 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (&gt;1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P &lt; .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22).

CONCLUSIONS

Antibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations.

Saccharomyces boulardii CNCM I-745 probiotic does not alter the pharmacokinetics of amoxicillin

Background Probiotics are live microbial organisms that provide benefit to the host while co-habitating in the gastrointestinal tract. Probiotics are safe, available over the counter, and have clinical benefit by reducing the number of antibiotic-associated diarrhea days. Prescriptions from providers and direct consumer demand of probiotics appear to be on the rise. Several recent animal studies have demonstrated that probiotics may have significant effect on absorption of co-administered drugs. However, to date, most probiotic-drug interaction studies in animal models have been limited to bacterial probiotics and nonantibiotic drugs. Methods We performed a traditional pharmacokinetic mouse study examining the interactions between a common commercially available yeast probiotic, Saccharomyces boulardii CNCM I-745 (Florastor®) and an orally administered amoxicillin. Results We showed that there were no significant differences in pharmacokinetic parameters (half-life, area under the curve, peak concentrations, time to reach maximum concentration, elimination rate constant) of amoxicillin between the probiotic treated and untreated control groups. Conclusions Altogether, our findings suggest that coadministration or concurrent use of S. boulardii probiotic and amoxicillin would not likely alter the efficacy of amoxicillin therapy.

Medical Management Strategies in Acute and Chronic Rhinosinusitis

Chronic rhinosinusitis, historically, has been considered to be caused by upper airway anatomical abnormalities. However, today that concept has changed, for it is now recognized as an inflammatory disorder of the nasal and sinus mucosa. Acute rhinosinusitis is usually caused by a viral infection, whereas chronic rhinosinusitis is a persistent and heterogeneous inflammatory disorder with increased expression of type 1, 2, or 17 cytokines in the nasal and sinus mucosa, similar to that which occurs in asthma. Exacerbations are caused by aeroallergens in the allergic individual and irritants, pollutants, and viral/bacterial infections in all subjects. It may be categorized by phenotypes, examples of which include chronic rhinosinusitis with nasal polyps or chronic rhinosinusitis without nasal polyps. Defined endotypes are based on underlying pathophysiological mechanisms. Knowledge of chronic rhinosinusitis endotypes will optimize management by employing targeted medical therapies. Understanding that rhinosinusitis is a heterogeneous inflammatory disease has led to the identification of a variety of different predisposing conditions, new medical treatment options, and the concept that rhinosinusitis is primarily a medical problem.

Choosing Wisely Canada rhinology recommendations

The Choosing Wisely Canada campaign is an initiative that aims to involve physicians and patients in collaborative decision making to avoid unnecessary tests and treatments. The Rhinology Subspecialty Group of the Canadian Society of Otolaryngology – Head & Neck Surgery developed a list of five evidence-based recommendations for the management of acute rhinosinusitis and nasal fractures: (1) don’t prescribe antibiotics to patients with acute sinusitis who do not meet the diagnostic criteria for acute bacterial rhinosinusitis; (2) don’t order a CT scan for uncomplicated acute rhinosinusitis; (3) don’t order plain film sinus x-rays; (4) don’t swab the nasal cavity as part of the work up for rhinosinusitis; and (5) don’t order a plain film x-ray in the evaluation of nasal fractures.

Antimicrobial prescribing in older adults

Infectious diseases pose a significant threat to older adult health and well-being. Determining the appropriate use and selection of antimicrobials in older adults can be challenging. Age-related physiologic changes, multiple comorbidities, and polypharmacy are factors that can make prescribing antimicrobials complicated and the effectiveness of therapy unpredictable.

Risk Factors for Unnecessary Antibiotic Prescribing for Acute Respiratory Tract Infections in Primary Care

Objective

To determine independent risk factors for inappropriate antibiotic prescribing for acute respiratory tract infections (ARIs) in internal medicine (IM) residency–based primary care offices.

Patients and Methods

A retrospective study was conducted to measure antibiotic prescribing rates, and multivariable analysis was utilized to identify predictors of inappropriate prescribing among patients presenting to IM residency–based primary care office practices. Patients with an office visit at either of 2 IM residency–based primary care office practices from January 1, 2016, through December 31, 2016, with a primary encounter diagnosis of ARI were included.

Results

During the study period, 911 unique patient encounters were included with 518 for conditions for which antibiotics were considered always inappropriate. Antibiotics were not indicated in 85.8% (782 of 911) of encounters. However, antibiotics were prescribed in 28.4% (222 of 782) of these encounters. Inappropriate antibiotic prescribing occurred in 111 of 518 (21.4%) encounters for conditions for which antibiotics are always inappropriate. Using multivariable logistic regression analysis to assess for independent risk factors when adjusted for other potential risk factors for office visits at which antibiotics were not indicated, IM resident–associated visits (odds ratio, 0.25; 95% CI, 0.18-0.36) was the only variable independently associated with lower risk of inappropriate antibiotic prescribing.

Conclusion

For ARI visits at which antibiotics were not indicated, IM resident comanagement was associated with lower rates of inappropriate prescribing.

Trends in complications of pediatric rhinosinusitis in the United States from 2006 to 2016

OBJECTIVES

1) Evaluate the changing prevalence of complications from pediatric acute bacterial rhinosinusitis and 2) elucidate factors associated with the development of complicated acute rhinosinusitis in this population.

STUDY DESIGN/SETTING

Cross-sectional analyses of the Kids' Inpatient Database.

SUBJECTS AND METHODS

Children <20 years with a diagnosis of acute rhinosinusitis were included. Diagnosis codes pertaining to acute rhinosinusitis-related complications were then queried for each subject. All patients were ultimately categorized into one of four groups: uncomplicated acute rhinosinusitis, orbital complications, intracranial complications, or both orbital and intracranial complications. Weighted measures were applied to provide national estimates.

RESULTS

Over the decade studied, national estimates for children admitted with acute rhinosinusitis decreased from 8,312 cases in 2006 to 5,592 in 2016. There was an increase in the rate of orbital complications from 8.9% to 19.3% and intracranial complications from 2.2% to 4.3%. Children with both complications increased from 0.5% to 1.0% of cases. Children with orbital complications were significantly younger (8.6 years) compared to those with intracranial complications (12.4 years) and both complication types (12.2 years) (p < 0.001).

CONCLUSION

Despite an overall decrease in cases of acute rhinosinusitis, rates of orbital and intracranial complications continued to increase over a ten-year period. Antibiotic prescribing patterns, vaccination effects, and evolving practice patterns may help explain these observations. Further studies warrant investigation into the cause of these trends.

LEVEL OF EVIDENCE

4.

Hospital utilization for orbital and intracranial complications of pediatric acute rhinosinusitis

BACKGROUND

Orbital and intracranial complications of pediatric acute rhinosinusitis (ARS) are uncommon. With a risk of significant morbidity, hospital utilization and the financial burden of these entities are often high. We sought to assess utilization trends for complicated ARS and elucidate which factors influence cost.

METHODOLOGY

Analysis of Kids' Inpatient Database (2006, 2009 and 2012). Children were selected based on diagnosis codes for ARS and grouped as: uncomplicated ARS, orbital complications (OC), or intracranial complications (IC). Patients with IC were subdivided into abscess (ICa), meningitis, or sinus thrombosis. Length of stay (LOS), cost and management information were analysed. Data presented as median [IQR].

RESULTS

A weighted total of 20,775 children were included. OC and IC were observed in 10.9% and 2.7% of these patients. LOS was longer for IC compared to OC (9 [8] v 4 [3]days, p < 0.001). Daily cost for IC was greater than OC ($2861 [4044] v $1683 [1187], p < 0.001), likely due to differences in need for surgery (IC 66.3% v OC 37.1%, p < 0.001). Within the ICa group, patients who received both otolaryngologic (ENT) and neurosurgery, compared to neurosurgery alone, had higher total cost ($41,474 [41,976] v $32,299 [18,235], p < 0.001) but similar LOS (12 [10] v 11 [9] days, p = 0.783).

CONCLUSIONS

Children with IC required more surgery than their OC counterparts, resulting in a longer LOS and increased cost. Within the ICa group, the addition of ENT surgery to neurosurgery resulted in higher costs, but with a similar LOS. Considering the increased costs, the additional benefit of ENT surgery to those with children with IC should be investigated further.

Ear, Nose, and Throat

This chapter reviews otolaryngology conditions most commonly seen by pediatricians. Included are issues involving the ears, nose, and nasopharynx; the sinuses, throat, mouth, and oropharynx; and the neck. The most common surgical otolaryngologic procedures will also be discussed. Many of these conditions can be effectively identified, diagnosed, and treated by primary care physicians. However, for certain conditions, prompt identification and timely referral to an otolaryngologist is required.

Management/Comorbidities of School-Aged Children with Asthma

Asthma is a complex heterogeneous disease characterized by reversible airflow obstruction. After appropriate diagnosis, the management in school-aged children centers on 3 broad domains: pharmacologic treatment, treatment of underlying comorbidities, and education of the patient and caregivers. It is important to understand that the phenotypic differences that exist in the school-aged child with asthma may impact underlying comorbid conditions as well as pharmacologic treatment choices. Following initiation of therapy, asthma control must be continually evaluated in order to optimize management.

Rational Prophylactic Antibiotic Selection for Sinus Elevation Surgery

FOCUSED CLINICAL QUESTION

For a generally healthy patient with no risk indicators for postoperative infection, what is the most appropriate perioperative antibiotic regimen for sinus elevation surgery in terms of reducing postoperative infection risk and minimizing untoward effects?

CLINICAL SCENARIO

A 38-year-old female patient in good general and periodontal health presents missing tooth #14 (Fig. ). She reports no systemic conditions, no history of sinusitis, and no allergies. Medications include acetaminophen and ibuprofen as needed for pain. The patient's dentition is minimally restored, with no active caries. Cone-beam computed tomography reveals a clear, pneumatized left maxillary sinus and inadequate bone volume to support dental implant placement (Fig. ). No septa or pathologic lesions are present, the ostium appears patent, and no thickening of the Schneiderian membrane is appreciable. The patient states that she wants to replace her missing molar without restoring adjacent teeth (Figs. and ). [Figure: see text] [Figure: see text] [Figure: see text] [Figure: see text].

Impact of β-Lactam Allergies on Antimicrobial Selection in an Outpatient Setting

OBJECTIVE

The primary objective of this study was to determine whether patients prescribed nonpreferred antibiotics received appropriate alternative antibiotics.

METHODS

This was a retrospective observational analysis of military veteran patients with a β-lactam allergy treated in an outpatient clinic or emergency department for an infection during a 5-year span. Antibiotic regimens were first stratified as preferred or nonpreferred based on infection-specific guidelines. The nonpreferred regimens were then evaluated for appropriateness based on allergy history and culture and sensitivity reports.

RESULTS

Of 445 fills of antibiotics evaluated, 269 met inclusion criteria, comprising 253 unique infections in 80 patients. Patients received nonpreferred antibiotics for their infection type in 57% of cases. Of the nonpreferred antibiotics, 56% were inappropriate based on guideline-recommended alternatives, allergy history, and culture and sensitivity data. Of the 88 allergies, 97% were historical/self-reported and 48% were cutaneous. In addition, 39% of patients safely received β-lactam antibiotics after documentation of their allergy.

CONCLUSIONS

Patients with documented β-lactam allergies are at high risk of receiving nonpreferred and inappropriate antibiotics, and many reactions likely do not reflect true allergies. These data emphasize the negative impact of the "β-lactam allergy" label and the importance of reassessing allergies.

Effectiveness of endoscopic versus external surgical approaches in the treatment of orbital complications of rhinosinusitis: a systematic review protocol

OBJECTIVE

This review aims to investigate and compare the effectiveness of endoscopic drainage techniques against external drainage techniques for the treatment of orbital and subperiosteal abscesses as a complication of rhinosinusitis.

INTRODUCTION

Transnasal endoscopic drainage and external drainage techniques have been used in the management of subperiosteal orbital abscesses secondary to rhinosinusitis. Each of these approaches has its own advantages and disadvantages, with extensive literature describing each technique separately. However, there is a lack of guidance in the studies on assessing and comparing the safety, effectiveness and suitability of these techniques. This review aims to compare the effectiveness of these techniques based on measuring outcomes in the literature such as: length of postoperative hospital stay, rate of revision surgery and complication rates.

INCLUSION CRITERIA

Eligible studies will include people of all ages diagnosed with subperiosteal abscess, orbital abscess or cavernous sinus thrombosis (Chandler stages III-V) secondary to rhinosinusitis disease, who have also undergone drainage via either an endoscopic approach, external approach or combined surgical approach.

METHODS

A comprehensive search of both published and unpublished literature will be performed to uncover studies meeting the inclusion criteria. Reference lists of studies included in final analyses will also be manually searched and subject matter experts contacted to investigate other sources of literature. Two reviewers will screen studies and a third reviewer will resolve disagreements. Studies will, where possible, be pooled in statistical meta-analysis with heterogeneity of data being assessed using the standard Chi-squared and I tests.

Impact of Beta-lactam Allergy on Treatment of Outpatient Infections

PURPOSE

The most commonly reported medication allergies in the United States involve beta-lactam antibiotics, creating an important consideration for prescribers when choosing optimal treatment of infections. Currently, few data exist on outpatient prescribing patterns in response to patients with a beta-lactam allergy. This study sought to evaluate the appropriateness of outpatient antibiotic therapy in patients with documented beta-lactam allergies within a Veterans Affairs health care system to evaluate areas of improvement in prescribing practices.

METHODS

Patients receiving outpatient oral antibiotics were prospectively identified through real-time electronic alerts from June 2017 through February 2018. Prescriptions were then reviewed retrospectively to identify appropriateness of antibiotic, drug choice, dose, and duration based on current guideline recommendations. Data were compared between patients with a listed beta-lactam allergy and patients without a beta-lactam allergy to determine the impact on prescribing patterns and outcomes. Baseline characteristics were compared by using descriptive statistics. Significant risk factors for inappropriate prescribing were identified through a multivariable analysis.

FINDINGS

The cohort included 1844 antibiotic prescriptions (documented beta-lactam allergy, 221; no beta-lactam allergy, 1623). Appropriate drug, dose, and duration for antibiotics prescribed in patients reporting a beta-lactam allergy versus nonallergic patients were 44.3% versus 53.0% (P = 0.02), 91.4% versus 86.2% (P = 0.03), and 75.1% versus 76.2% (P = 0.83), respectively. Patients with a reported beta-lactam allergy were 31% less likely to receive the correct drug for indication empirically (95% CI, 0.52-0.92) in the multivariable regression model when adjusted for fluoroquinolone use. In addition, patients reporting a beta-lactam allergy were 2.2 times (95% CI, 1.6-3.0) more likely to receive a fluoroquinolone antibiotic. Antibiotics were considered overall inappropriate based on at least one aspect of therapy in 79.6% of patients reporting a beta-lactam allergy and in 71% of nonallergic patients.

IMPLICATIONS

Antibiotic therapy in patients with a documented beta-lactam allergy was less likely to be appropriate overall, suggesting an area of improvement for prescribing habits. Future interventions should focus on prescriber education regarding first-line and alternative treatments for patients with beta-lactam allergies to ensure that optimal treatment is being provided.

Low Risk of Primary Clostridium difficile Infection With Tetracyclines: A Systematic Review and Metaanalysis

Background

The choice of antibiotics for systemic infections in patients with a high risk of Clostridium difficile infection (CDI) remains a clinical practice dilemma. Although some studies suggest that tetracyclines may be associated with a lower risk of CDI than other antibiotics, other results are conflicting. We conducted a systematic review and metaanalysis of studies that assessed the risk of CDI with tetracyclines compared to other antibiotics.

Methods

We conducted a systematic search of Medline, Embase, and Web of Science from January 1978 through December 2016 to include studies that assessed the association between tetracycline use and risk of CDI. Weighted summary estimates were calculated using generalized inverse variance with a random-effects model using RevMan 5.3. Study quality was assessed using the Newcastle-Ottawa scale.

Results

Six studies (4 case control, 2 cohort) with patient recruitment between 1993 and 2012 were included. Metaanalysis using a random-effects model, demonstrated that tetracyclines were associated with a decreased risk of CDI (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.47-0.81; P < .001). There was significant heterogeneity, with an I2 of 53% with no publication bias. Subgroup analysis of studies that evaluated the risk of CDI with doxycycline alone also demonstrated a decreased risk of CDI (OR, 0.55; 95% CI, 0.40-0.75; P < .001).

Conclusions

Metaanalyses of existing studies suggest that tetracyclines may be associated with a decreased risk of CDI compared with other antimicrobials. It may be reasonable to use tetracyclines whenever appropriate to decrease CDI associated with antibiotic use.

Analysis of antibiotic use in a large network of emergency departments

Purpose

To assess antibiotic selection, administration, and prescribing practices in emergency departments across a large hospital system using evidence-based practices and susceptibility patterns.

Methods

This retrospective data review was conducted using health system–level electronic data compiled from 145 emergency departments (EDs) across the United States. Data were examined for national generalizability, most common diagnoses of infectious origin seen in nonadmitted patients in the ED, most commonly administered antibiotics in the ED, and geographically defined areas’ unique patterns of antibiotic resistance and susceptibility.

Results

More than 627,000 unique patient encounters and 780,000 antibiotic administrations were assessed for trends in patient demographics, antibiotics administered for a diagnosis of infectious origin, and corresponding susceptibility patterns. Results indicated that practices in the EDs of this health system aligned with evidence-based practices for streptococcal pharyngitis, otitis media, cellulitis, and uncomplicated urinary tract infections.

Conclusion

These results provide a representative sample of the current state of practices within many EDs across the United States for nonadmitted patients. A similar data reconstruction can be completed by other health systems to assess their prescribing practices in the ED to improve and elevate care for patients visiting the emergency room and treated as outpatients.

Points to consider before the insertion of maxillary implants: the otolaryngologist's perspective

Maxillary implants are inserted in the upward direction, meaning that they oppose gravity, and achieving stable support is difficult if the alveolar bone facing the maxillary sinus is thin. Correspondingly, several sinus-lifting procedures conducted with or without bone graft materials have been used to place implants in the posterior area of the maxilla. Even with these procedures available, it has been reported that in about 5% of cases, complications occurred after implantation, including acute and chronic sinusitis, penetration of the sinus by the implant, implant dislocation, oroantral fistula formation, infection, bone graft dislocation, foreign-body reaction, Schneiderian membrane perforation, and ostium plugging by a dislodged bone graft. This review summarizes common maxillary sinus pathologies related to implants and suggests an appropriate management plan for patients requiring dental implantation.

Comparison of Diagnosis and Prescribing Practices Between Virtual Visits and Office Visits for Adults Diagnosed With Sinusitis Within a Primary Care Network

Background

Many antibiotics prescribed in the outpatient setting result from upper respiratory tract infections (URTIs); however, these infections are often viral. Virtual visits have emerged as a popular alternative to office visits for URTIs and may be an important target for antimicrobial stewardship programs.

Methods

This retrospective cohort study evaluated adult patients diagnosed with sinusitis treated within a single primary care network. The primary objective was to compare guideline-concordant diagnosis between patients treated via virtual visits vs in-office visits. Guideline-concordant bacterial sinusitis diagnosis was based on national guideline recommendations. Secondary objectives included comparing guideline-concordant antibiotic prescribing between groups and 24-hour, 7-day, and 30-day revisits.

Results

A total of 350 patients were included in the study, with 175 in each group. Patients treated for sinusitis were more likely to receive a guideline-concordant diagnosis in the virtual visit group (69.1% vs 45.7%; P < .001). Additionally, patients who completed virtual visits were less likely to receive antibiotics (68.6% vs 94.3%; P < .001). Guideline-concordant antibiotic selection was similar between groups (67.5% vs 64.8%; P = .641). The median duration of therapy in both groups was 10 days (P = .88). Patients completing virtual visits were more likely to revisit for sinusitis within 24 hours (8% vs 1.7%; P = .006) and within 30 days (14.9% vs 7.4%; P = .027).

Conclusions

In adult patients presenting with sinusitis, care at a virtual visit was associated with an increase in guideline-concordant diagnosis and a decrease in antibiotic prescribing compared with in-office primary care visits. Virtual visit platforms may be a valuable tool for antimicrobial stewardship programs in the outpatient setting.

Impact of an Antibiotic Stewardship Program on Antibiotic Prescription for Acute Respiratory Tract Infections in Children: A Prospective Before-After Study

We assessed the effectiveness of an antibiotic stewardship program (ASP) on antibiotic prescriptions for acute respiratory tract infection (ARTI) in a medical school. Our ASP included delivering an antibiotic use guideline via e-mail and LINE (an instant messaging app) to faculty staff, fellows, and residents, and posting of the guideline in examination rooms. Medical records of pediatric patients diagnosed with ARTI were reviewed to assess the appropriateness of antibiotic prescription. ASP could increase the rate of appropriateness from 78% (1979 out of 2553 visits) to 83.4% (2449 out of 2935 visits; P < .001). The baseline of appropriateness was higher in residents (95%) compared with fellows (82%) and faculty staff (75%). The ASP significantly increased the appropriateness only in faculty staff, especially in semiprivate clinics (75% to 83%, P < .001). In conclusion, our ASP increased appropriateness of antibiotic prescriptions for ARTI, with the greatest impact among faculty staff in semiprivate clinics.

Long-term improvement of clinical symptoms after endoscopic sinus surgery in patients suffered from endocrine ophthalmopathy and orbital complications of rhinosinusitis

Background: Rhinosinusitis may cause serious complications, such as secondary orbital infections, resulting in expansion and erosion of process through the orbital wall. Aims: The aim is to evaluate long-term outcome of ESS in patients suffered from endocrine ophthalmopathy and orbital complications of rhinosinusitis. Material and methods: Thirteen patients with loss of vision, endocrine ophthalmopathy and orbital complication of rhinosinusitis were treated by ESS. Preoperative and postoperative vision was rated by best-corrected visual acuity (BCVA) testing. Nine (69%) have been reinvestigated after 6 years by ophthalmology examination and 10-point scale for assessment of clinical symptoms. Results: The mean BCVA significantly increased after surgery comparing to results before surgery (0.84, 0.62; respectively) (p = .007). The mean values of 10-point scale for subjective assessment of symptoms 6 years after surgery were: headache 2.11, sinonasal pressure 1.72, subjective estimation of vision quality on the affected eye was 7.33 and olfaction 7.66. None of the patients developed impairment of vision loss in postoperative period. Conclusions: Long-term outcome of ESS showed decreased symptoms in patients who had endocrine ophthalmopathy and orbital complication of rhinosinusitis. Significance: ESS has numerous advantages for patients with orbital complication and vision loss comparing to conservative treatment and should be considered even in abscess absence.

"Sinus Headache": Diagnosis and Dilemma?? An Analytical and Prospective Study

To evaluate the type, location, severity of headache and their relation to various nasal and sinus related pathological conditions. All the patients presenting with acute and chronic sinus and nasal infections along with headache were included in the study. The diagnostic confirmation was done with clinical along with radiological and endoscopic evaluation. Various parameters categorized accordingly. Chronic rhinosinusitis/chronic recurrent rhinosinusitis are the most common nasal condition seen in oto-rhino-laryngology OPD which has enormous economic burden and significant morbidity on general population. The headache is the commonest associated symptom which is needed to be given attention. The location, variation, pattern of the headache can guide us towards the correct diagnosis.

Outpatient antibiotic prescribing patterns in pediatric academic and community practices

Little is known about antibiotic prescribing differences between academic and community outpatient settings. This retrospective, cross-sectional chart review compares compliance with Infectious Diseases Society of America and American Academy of Pediatrics prescribing guidelines for otitis media, sinusitis, and pharyngitis in academic and affiliated community practices. The study results for correct antibiotic prescribing rate in the academic setting (67%) compared with the community setting (21%) demonstrate the urgent need for stewardship in community outpatient clinics.

Review of Systemic Antibiotic Treatments in Children with Rhinosinusitis

Antibiotic treatment in paediatric rhinosinusitis is still a matter of debate, as the current guidelines have been drafted mainly based on clinical studies published before 2013. Recent modifications in the epidemiological basis of the disease might mean that current treatments are not completely adequate considering the evolving microbiological profile of the disease. The present paper reviews the role of systemic antibiotics in children with acute (ARS), chronic (CRS), recurrent (RARS), and complicated acute (CoARS) rhinosinusitis. A total of 14 studies (including 3 prospective non-randomised studies, 8 retrospective studies, and 3 prospective randomised studies) of the 115 initially identified papers were included in this review, corresponding to 13,425 patients. Five papers dealt with ARS, four papers with RARS or CRS, and five papers with CoARS; the remaining papers included patients with either ARS or CRS. Data about the effectiveness of antibiotic treatment in children with ARC, CRS, and CoARS is scarce, as only three randomised controlled trials have been published in the last decade, with contrasting results. There is an urgent need for dedicated controlled trials not only to test the actual clinical benefits deriving from the routine use of systemic antibiotics in different categories of patients but also to compare the effectiveness of various therapeutic protocols in terms of the type of antibacterial molecules and the duration of treatment.

Antibiotic stewardship targets in the outpatient setting

BACKGROUND

Outpatient prescriptions comprise 60% of antibiotic use. This study prospectively identified inappropriate antibiotic use enabling a focused approach to outpatient antimicrobial stewardship.

METHODS

Outpatients at the Veterans Affairs Western New York Healthcare System were identified via an electronic antibiotic alert from June 2017 to September 2017. Descriptive statistics and multivariable logistic regression identified stewardship targets.

RESULTS

Of the 1,063 patients, 40% of antibiotic prescriptions were not indicated. Urinary tract infections (21%), bronchitis (20%), skin structure infections (17%), and sinusitis (10%) were common causes of inappropriate antibiotic use. Azithromycin (37%) was prescribed unnecessarily most often, followed by ciprofloxacin (16%), amoxicillin/clavulanate (13%), and cephalexin (12%). The correct drug was chosen in 52%, dose in 81%, and duration in 75% of patients. When the antibiotic was indicated, the correct drug was 2.9 times more likely to be prescribed and 2 times more likely to have the correct duration and receive care in the emergency room.

DISCUSSION

Focusing on 4 drugs; amoxicillin/clavulanate, azithromycin, ciprofloxacin, and cephalexin accounted for 80% of unnecessary drug use. This study provides a guide to concentrate efforts during implementation of an outpatient stewardship program.

CONCLUSIONS

Poor antibiotic prescribing was found in the outpatient setting. This study identifies areas for improvement via stewardship.

Pattern of antibiotic prescriptions for outpatients with acute respiratory tract infections in Japan, 2013-15: a retrospective observational study

BACKGROUND

In this age of antimicrobial resistance, unnecessary use of antibiotics to treat non-bacterial acute respiratory tract infections (ARTIs) and inappropriate use of antibiotics in treating bacterial ARTIs are public health concerns.

PURPOSE

Our aim is to identify the pattern of oral antibiotic prescriptions for outpatients with ARTIs in Japan.

METHODS

We analysed health insurance claims data of patients (aged ≤74 years) from 2013 to 2015, to determine the pattern of antibiotic prescriptions for outpatient ARTIs and calculated the proportion of each antibiotic.

RESULTS

Data on 4.6 million antibiotic prescriptions among 1559394 outpatients with ARTIs were analysed. The most commonly prescribed classes of antibiotics included cephalosporins (41.9%), macrolides (32.8%) and fluoroquinolones (14.7%). The proportion of first-, second- and third-generation cephalosporins was 1.0%, 1.7% and 97.3%, respectively. Fluoroquinolones accounted for a quarter of the prescriptions for ARTIs in patients aged >20 years. In contrast, penicillins accounted for just 8.0% of the total number of antibiotic prescriptions for ARTIs.

CONCLUSIONS

According to clinical guidelines, penicillins are first-line antibiotics against ARTIs. However, third-generation cephalosporins, macrolides and fluoroquinolones are more frequently prescribed in Japan. Although we could not assess the extent to which appropriate antibiotics are selected, our results support the necessity of improving antibiotic choices in the treatment of ARTIs.

Impact of Education and Peer Comparison on Antibiotic Prescribing for Pediatric Respiratory Tract Infections

Supplemental Digital Content is available in the text.

Introduction:

Inappropriate prescribing of broad-spectrum antibiotics is a significant modifiable risk factor for the development of antibiotic resistance. The objective was to improve guideline-concordant care for 3 common acute respiratory tract infections (ARTIs) and to reduce broad-spectrum antibiotic prescribing in ambulatory pediatric patients.

Methods:

Quality measures were developed for 3 ARTIs: viral upper respiratory infection (URI), acute bacterial sinusitis (ABS), and acute otitis media (AOM). Among 22 pediatric clinics, a collaborative of 10 was identified for intervention using baseline data for each ARTI, and 3 plan-do-study-act cycles were planned and completed. Outcomes included guideline-concordant antibiotic utilization and broad-spectrum antibiotic prescribing percentage (BSAP%). Comparison in number of diagnoses for the ARTI measures and total antibiotic prescribing over time served as balancing measures.

Results:

Collaborative clinics had baseline medians for appropriate or first-line treatment of 70% for URI, 53% for ABS, and 36% for AOM. To reach targets for URI, ABS, and AOM required 6, 14, and 18 months, respectively. At 42 months, performance for all 3 ARTIs remained ≥90%. BSAP% decreased from a baseline of 57% to 34% at 24 months. There was a limited effect from financial incentives but a significant decrease was noted in total antibiotic utilization. Diagnosis shifting may have occurred for URI and ABS while the rates for diagnoses for AOM declined over time.

Conclusions:

Through education and peer comparison feedback, guideline-concordant care for 3 ARTIs in collaborative clinics improved and remained beyond above targets and was accompanied by reductions in BSAP% and total antibiotic prescribing.

The Basics of Penicillin Allergy: What A Clinician Should Know

Antimicrobials in the penicillin class are first line treatments for several infectious diseases in the pediatric and adult population today. In the United States, patients commonly report having a penicillin allergy, with penicillin being the most frequent beta-lactam allergy. However, very few patients experience a clinically significant immune-mediated allergic reaction to penicillin. If a true penicillin allergy exists, cross-reactivity to other beta-lactam antimicrobials may occur. Mislabeling patients with penicillin allergy can lead to a higher utilization of second line antimicrobial agents, potentially increasing costs and resistance due to a larger spectrum of activity. Pharmacists play an essential role in inquiring about patient specific reactions to presumed medication allergies and developing a further assessment plan, if needed, to determine if the medication allergy is real.

Quality Of Care For Acute Respiratory Infections During Direct-To-Consumer Telemedicine Visits For Adults

In direct-to-consumer telemedicine, physicians treat patients through real-time audiovisual conferencing for common conditions such as acute respiratory infections. Early studies had mixed findings on the quality of care provided during direct-to-consumer telemedicine and were limited by small sample sizes and narrow geographic scopes. Using claims data for 2015-16 from a large national commercial insurer, we examined the quality of antibiotic management in adults with acute respiratory infection diagnoses at 38,839 direct-to-consumer telemedicine visits, compared to the quality at 942,613 matched primary care visits and 186,016 matched urgent care visits. In the matched analyses, we found clinically similar rates of antibiotic use, broad-spectrum antibiotic use, and guideline-concordant antibiotic management. However, direct-to-consumer telemedicine visits had less appropriate streptococcal testing and a higher frequency of follow-up visits. These results suggest specific opportunities for improvement in direct-to-consumer telemedicine quality.

Behavioral Economics Interventions to Improve Outpatient Antibiotic Prescribing for Acute Respiratory Infections: a Cost-Effectiveness Analysis

BACKGROUND

Behavioral economics interventions have been shown to effectively reduce the rates of inappropriate antibiotic prescriptions for acute respiratory infections (ARIs).

OBJECTIVE

To determine the cost-effectiveness of three behavioral economic interventions designed to reduce inappropriate antibiotic prescriptions for ARIs.

DESIGN

Thirty-year Markov model from the US societal perspective with inputs derived from the literature and CDC surveillance data.

SUBJECTS

Forty-five-year-old adults with signs and symptoms of ARI presenting to a healthcare provider.

INTERVENTIONS

(1) Provider education on guidelines for the appropriate treatment of ARIs; (2) Suggested Alternatives, which utilizes computerized clinical decision support to suggest non-antibiotic treatment choices in lieu of antibiotics; (3) Accountable Justification, which mandates free-text justification into the patient's electronic health record when antibiotics are prescribed; and (4) Peer Comparison, which sends a periodic email to prescribers about his/her rate of inappropriate antibiotic prescribing relative to clinician colleagues.

MAIN MEASURES

Discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios.

KEY RESULTS

Each intervention has lower costs but higher QALYs compared to provider education. Total costs for each intervention were $178.21, $173.22, $172.82, and $172.52, and total QALYs were 14.68, 14.73, 14.74, and 14.74 for the control, Suggested Alternatives, Accountable Justification, and Peer Comparison groups, respectively. Results were most sensitive to the quality-of-life of the uninfected state, and the likelihood and costs for antibiotic-associated adverse events.

CONCLUSIONS

Behavioral economics interventions can be cost-effective strategies for reducing inappropriate antibiotic prescriptions by reducing healthcare resource utilization.

Effectiveness of clinical pathway for upper respiratory tract infections in emergency department

OBJECTIVE

We aimed to demonstrate the benefits of implementing a clinical pathway to decrease the inappropriate use of antibiotics in upper respiratory tract infections (URTI) in an emergency department (ED).

METHODS

The study was performed in a hospital with 300 beds. All patients who applied with URTI from 1st to 30th of April 2017 were included and the appropriateness of the antibiotics were compared with the patients in the same period in 2016. A checklist for the clinical pathway of URTI was completed by the ED physicians.

RESULTS

351 patients were included, 176 these patients were in pre-ASP period and 175 patients were in post-ASP period. The rate of prescriptions including antibiotics was 49% in pre-ASP period and has decreased to 29% in post-ASP period (p < 0.001). Adherence to clinical pathway has increased from 50% to 80% (p < 0.001). In the post-ASP period, clinical pathway was used in 133 out of 175 patients (76%) and the consequently rate of appropriate antibiotic use was 82%.

CONCLUSION

The implementation of clinical pathway for URTI has decreased inappropriate antibiotic use in ED. As the secondary effect, using clinical pathway in ED also has increased the awareness of ED physicians who did not adhere to clinical pathway.

Clinical Guidelines on Chronic Rhinosinusitis in Children

PURPOSE OF REVIEW

Pediatric chronic rhinosinusitis (CRS) is a prevalent problem that can elude diagnosis. In addition, given the burgeoning interest in pediatric sinonasal disease, treatment modalities are constantly evolving.

RECENT FINDINGS

The diagnosis of pediatric CRS is primarily based on clinical history and signs supported by objective findings (i.e., nasal endoscopy and/or computed tomography (CT) imaging). Cultures are indicated in patients who have not responded to medical therapy or have significant comorbidities. Nasal saline irrigation, nasal saline spray, and oral antibiotics are currently recommended for initial medical management. In children with CRS who have failed medical therapy, a stepwise approach to surgical intervention can lead to significant improvements in quality of life. This review provides an overview of the current guidelines and recent literature regarding the diagnosis, microbiology, and treatment options of CRS in the pediatric population.

Human metapneumovirus infection: Diagnostic impact of radiologic imaging

Background

Human metapneumovirus (hMPV) is a recently detected virus, which can cause mild to severe respiratory tract infections. Through this study, we aimed to detail the outcomes of hMPV infections.

Materials/methods

Between January 2012 and November 2017, patients who had hMPV detected in nasopharyngeal or bronchoalveolar lavage by molecular respiratory pathogen tests were evaluated. The Food and Drug Administration cleared multiplexed‐polymerase chain reaction system (Idaho Technology, Salt Lake City, UT) was used for diagnosis. Chest radiography (CR) and computed tomography (CT) were evaluated by an expert radiologist.

Results

In total 100 patients were included, the mean age was 22.9 (0‐87) years, and 50% were male. The hospitalization rate was 52%. Lower respiratory system infection (LRTI) was diagnosed in 44 patients with clinical findings, and in 31 patients out of 44 the radiological findings supported the diagnosis. The LRTI rate was significantly higher in adults than children (66.7%‐32.8%; P = 0.001). In CR, peribronchovascular infiltration (PI) was the most common feature seen in 14 out of 18 patients and was generally bilateral (13 out of 18 patients). In CT imaging, ground‐glass opacity was the most common finding seen in 11 out of 16 patients and nodular consolidation in five patients. Ribavirin was given to four patients, three of whom were severe and required respiratory support. None of the patients died of hMPV infection.

Conclusions

The ground‐glass opacity in CT was similar to other respiratory virus infections, and PI in CR was very common and typical; however, nodular consolidation that may mimic bacterial infection was seen in one‐fourth of CT.

Human metapneumovirus (hMPV) is a recently detected virus which can cause mild to severe respiratory tract infections. Nodular consolidation that may mimics bacterial infection was detected in one fourth of CT administered patients. Clinicians should be alert that hMPV infection may present like a bacterial LRTI in radiologic imaging.