Antibiotic prescriptions for outpatient acute rhinosinusitis in Canada, 2007-2013

Hospitalizations and severe complications following acute sinusitis in general practice: a registry-based cohort study

OBJECTIVES

To investigate complication rates of acute sinusitis in general practice, and whether antibiotic prescribing had an impact on complication rate.

METHODS

All adult patients diagnosed with sinusitis in Norwegian general practice between 1 July 2012 and 30 June 2019 were included. GP consultation data from the Norwegian Control and Payment for Health Reimbursements Database were linked with antibiotic prescriptions (Norwegian Prescription Database) and hospital admissions (Norwegian Patient Registry). Main outcomes were sinusitis-related hospitalizations and severe complications within 30 days. Logistic regression was used to estimate associations between antibiotic prescriptions, prespecified risk factors, individual GP prescribing quintile, and outcomes.

RESULTS

A total of 711 069 episodes of acute sinusitis in 415 781 patients were identified. During the study period, both annual episode rate (from 30.2 to 21.2 per 1000 inhabitants) and antibiotic prescription rate (63.3% to 46.5%; P < 0.001) decreased. Yearly hospitalization rate was stable at 10.0 cases per 10 000 sinusitis episodes and the corresponding rate of severe complications was 3.2, with no yearly change (P = 0.765). Antibiotic prescribing was associated with increased risk of hospitalization [adjusted OR 1.8 (95% CI 1.5-2.1)] but not with severe complications. Individual GP prescribing quintile was not associated with any of the outcomes, whereas risk factors such as previous drug abuse, or head injury, skull surgery or malformations, and being immunocompromised were significantly associated with increased risk of both outcomes.

CONCLUSIONS

Severe complications of acute sinusitis were rare and no protective effect of high prescribing practice among GPs was found. Recommendations to further reduce antibiotic prescribing are generally encouraged, except for high-risk groups.

Chinese herbal therapy in the management of rhinosinusitis-A systematic review and meta-analysis

This systematic review aims to assess the effects and safety of Chinese herbal medicines (CHMs) in the management of rhinosinusitis (RS); inform clinicians of the current state of the evidence; identify the best available evidence; and suggest further directions for research. Five English and four Chinese language databases, and four clinical trial registries were searched. Eligible studies were randomised controlled trials (RCTs). Participants were diagnosed with RS based on established criteria. Test interventions were CHMs administered orally and/or nasally, excluding injections and displacement techniques. Control interventions included placebos, no additional treatment, and conventional non-invasive treatments including pharmacotherapies and/or nasal irrigation, and/or inhalations. Polyposis and post-surgical recovery were excluded. Outcomes were Sino-Nasal Outcome Test (SNOT), visual analogue scales (VAS), Lund-Mackay computed tomography score (LM), Lund-Kennedy Endoscopic score (LK), Mucociliary transport time (MTT), Mucociliary transport rate (MTR), quality of life and adverse events (AEs). Risk of bias used the Cochrane tool. Meta-analysis in Review Manager 5.4.1 used random effects for mean difference (MD) or risk ratio (RR) with 95% confidence intervals. Heterogeneity was assessed as I2. Thirty-four RCTs were included, 30 of chronic RS (CRS) and four of acute RS (ARS). These enrolled 3,752 participants. Five RCTs blinded participants. For CRS, comparisons with placebo showed greater improvements in the CHM groups for SNOT-20 and VAS-TNS (total nasal symptoms). Blinded comparisons with pharmacotherapies showed no differences between groups in the degree of improvement for SNOT-20, VAS-TNS, and LM, suggesting these CHMs had similar effects, at least in the short term. In ARS, pooled results found improved scores on VAS-TNS and LK suggesting a benefit for combining these CHMs with pharmacotherapies. Limitations included inadequacies in study design and methodological reporting, and insufficient reporting of AEs. Heterogeneity in some pooled results precluded strong conclusions. Further well-designed studies are needed to test whether the results are replicable. Systematic review registration number: PROSPERO (CRD42019119586).

Effect of unifaceted and multifaceted interventions on antibiotic prescription control for respiratory diseases: A systematic review of randomized controlled trials

BACKGROUND

The global health system is improperly using antibiotics, particularly in the treatment of respiratory diseases. We aimed to examine the effectiveness of implementing a unifaceted and multifaceted intervention for unreasonable antibiotic prescriptions.

METHODS

Relevant literature published in the databases of Pubmed, Embase, Science Direct, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure and Wanfang was searched. Data were independently filtered and extracted by 2 reviewers based on a pre-designed inclusion and exclusion criteria. The Cochrane collaborative bias risk tool was used to evaluate the quality of the included randomized controlled trials studies.

RESULTS

A total of 1390 studies were obtained of which 23 studies the outcome variables were antibiotic prescription rates with the number of prescriptions and intervention details were included in the systematic review. Twenty-two of the studies involved educational interventions for doctors, including: online training using email, web pages and webinar, antibiotic guidelines for information dissemination measures by email, postal or telephone reminder, training doctors in communication skills, short-term interactive educational seminars, and short-term field training sessions. Seventeen studies of interventions for health care workers also included: regular or irregular assessment/audit of antibiotic prescriptions, prescription recommendations from experts and peers delivered at a meeting or online, publicly reporting on doctors' antibiotic usage to patients, hospital administrators, and health authorities, monitoring/feedback prescribing behavior to general practices by email or poster, and studies involving patients and their families (n = 8). Twenty-one randomized controlled trials were rated as having a low risk of bias while 2 randomized controlled trials were rated as having a high risk of bias. Six studies contained negative results.

CONCLUSION

The combination of education, prescription audit, prescription recommendations from experts, public reporting, prescription feedback and patient or family member multifaceted interventions can effectively reduce antibiotic prescription rates in health care institutions. Moreover, adding multifaceted interventions to educational interventions can control antibiotic prescription rates and may be a more reasonable method.

REGISTRATIONS

This systematic review was registered in PROSPERO, registration number: CRD42020192560.

[The evolution of methods of active irrigation of paranasal sinuses in rhinosinusitis. Part 2]

Inflammation of the paranasal sinuses significantly reduces the quality of life of people and causes marked economic damage to society. The striking clinical picture of sinusitis has always forced doctors to study the disease, as evidenced by the first records of the anatomy and diseases of the paranasal sinuses by doctors in ancient Egypt more than 3.000 years BC. Sinusitis has been treated in different ways in different historical periods. Effective medication treatment appeared relatively recently and began to steadily replace the older instrumental methods, to which many people had a preconceived notion of invasiveness. However, many studies are showing the positive effect of active drainage methods and, moreover, there is data showing that the discomfort during such procedures is slightly higher than during dental treatment under local anesthesia. This article presents a review of the available scientific literature on the use of different treatments for bacterial rhinosinusitis at different historical stages, ranging from the first publications on puncture techniques to balloon dilatation and the modern approach to conservative treatment.

Regional variation in the potentially inappropriate first-line use of fluoroquinolones in Canada as a key to antibiotic stewardship? A drug utilization review study

Background

Serious adverse effects of fluoroquinolone antibiotics have been described for more than decade. Recently, several drug regulatory agencies have advised restricting their use in milder infections for which other treatments are available, given the potential for disabling and possibly persistent side effects. We aimed to describe variations in fluoroquinolone use for initial treatment of urinary tract infection (UTI), acute bacterial sinusitis (ABS), and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the outpatient setting across Canada.

Methods

Using administrative health data from six provinces, we identified ambulatory visits with a diagnosis of uncomplicated UTI, uncomplicated AECOPD or ABS. Antibiotic exposure was determined by the first antibiotic dispensed within 5 days of the visit.

Results

We identified 4,303,144 uncomplicated UTI events among 2,170,027 women; the proportion of events treated with fluoroquinolones, mostly ciprofloxacin, varied across provinces, ranging from 18.6% (Saskatchewan) to 51.6% (Alberta). Among 3,467,678 ABS events (2,087,934 patients), between 2.2% (Nova Scotia) and 11.2% (Ontario) were dispensed a fluoroquinolone. For 1,319,128 AECOPD events among 598,347 patients, fluoroquinolones, mostly levofloxacin and moxifloxacin, ranged from 5.8% (Nova Scotia) to 35.6% (Ontario). The proportion of uncomplicated UTI and ABS events treated with fluoroquinolones declined over time, whereas it remained relatively stable for AECOPD.

Conclusions

Fluoroquinolones were commonly used as first-line therapies for uncomplicated UTI and AECOPD. However, their use varied widely across provinces. Drug insurance formulary criteria and enforcement may be a key to facilitating better antibiotic stewardship and limiting potentially inappropriate first-line use of fluoroquinolones.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06467-z.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Evidence-based management of acute rhinosinusitis with herbal products

Background

The overuse of antibiotics for unjustified indications such as the management of acute uncomplicated rhinosinusitis has contributed to the emergence of antibiotic-resistant strains of bacteria and prompted the need for alternative treatments. This review assesses the quality of evidence for the management of acute rhinosinusitis with herbal products, with the goal of positioning them among other treatments and identifying future research directions. The MEDLINE database was searched for randomized controlled trials with Sinupret®, Pelargonium sidoides extract, Cyclamen europaeum (CE), cineole, and GeloMyrtol®. Searches with N-acetylcysteine and mometasone furoate nasal spray (MFNS) were performed to compare the strength of evidence of herbal products to these conventional products, which are indicated for acute rhinosinusitis.

Main body

Evidence was strongest for Sinupret, followed by Pelargonium sidoides extract. Their use in acute rhinosinusitis is supported by randomized placebo-controlled trials demonstrating both clinical efficacy and safety. Comparative data with conventional treatments such as topical glucocorticosteroids were found only for Sinupret and suggested comparable efficacy in a small study.

For other herbal products, the overall level of evidence was low. The search retrieved two small-scale placebo-controlled randomized studies with CE nasal spray. The two trials were not powered to draw conclusions about the safety and efficacy of CE nasal spray and reported a lack of efficacy with CE on symptom reduction. Only one randomized placebo-controlled trial was identified for GeloMyrtol and cineole. These suggested an improvement in acute rhinosinusitis symptoms with both products, but the results warrant replication in larger trials.

Studies directly comparing herbal products are scarce; one randomized trial has compared cineole with Sinupret, but the results need confirmation in further studies.

Studies with N-acetylcysteine are limited to small-scale clinical trials, while MFNS is supported by a strength of evidence comparable to Sinupret in this indication.

Conclusion

State-of-the-art studies demonstrating the efficacy and safety of herbal products for the management of acute rhinosinusitis are available. Given that the evidence for Sinupret is the strongest and comparable to that of a widely available topical corticosteroid, MFNS, Sinupret may be considered for the management of acute uncomplicated rhinosinusitis.

Clinical pattern of antibiotic overuse and misuse in primary healthcare hospitals in the southwest of China

Purpose

Overuse and misuse of antibiotics are the primary risk factors for antibiotics resistance. Inadequate professional competence of primary care physicians might exacerbate these problems in China. This retrospective study aims to document the clinical pattern of antibiotics use and its overuse and misuse rates in rural primary care institutions and to evaluate the association between antibiotics use and characteristics of physicians and their patients.

Methods

Medical records from 16 primary care hospitals in rural areas of Guizhou province, China were obtained from the Health Information System in 2018. Classification of unnecessary use, incorrect spectrum of antibiotic, escalated use of extended spectrum and combined antibiotics use was based on the Guiding Principle of Clinical Use of Antibiotics (2015, China) and guidelines from the US Centers for Disease Control and Prevention. Generalized Estimating Equations were employed to determine predictive factors for inappropriate antibiotics use.

Results

A total of 74,648 antibiotics prescriptions were retrieved. Uncomplicated respiratory infection was the most common disease accounting for 58.6% of all prescriptions. The main antibiotic group used was penicillins (51.5%) followed by cephalosporins and macrolides (14% each). Of 57,009 patient visits, only 8.7% of the antibiotic prescriptions were appropriate. Combined use, escalated use of extended spectrum antibiotics, incorrect spectrum and unnecessary antibiotics use was found in 7.8%, 1.9%, 4.3% and 77.3% of patient visits, respectively, of which 28.7% were given intravenously. Antibiotics misuse was significantly more likely among newly employed physicians with lower levels of professional education. Adult patients and those who had public insurance had a higher risk of being prescribed unnecessary antibiotics.

Conclusion

Overuse of antibiotics for uncomplicated respiratory infection and use of cephalosporins, macrolides and injection antibiotics in primary care are the major problems of clinical practice in rural areas of Guizhou.

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.

Point-of-Care Sinus Ultrasound: Impact Within a Large Internal Medicine Clinic and Review of Technique

Outpatient diagnosis of acute bacterial sinusitis, using only traditional physical examination and clinical criteria, results in the overuse of antibiotics in patients with upper respiratory complaints. Point-of-care maxillary sinus ultrasound is easy to learn and quick to perform in a primary care clinic. The technique can reduce antibiotic prescribing by reassuring both patients and providers of the absence of fluid in the sinus, the hallmark of maxillary sinusitis. A review of the literature, description of technique, and results of sinus ultrasound implementation in a large internal medicine clinic are included.