Axel Vazquez Deida, PharmD, MPH, BCIDP
Image credits: ACIP
There are ongoing opportunities to refine antibiotic agent selection and treatment duration, particularly in rural areas and urgent care settings. Identifying these specific factors related to antibiotic prescribing can lead to the development of more targeted and effective antibiotic stewardship interventions.
Among 4,689,850 sinusitis encounters, 53% involved antibiotics that followed guidelines, 30% did not, and 17% received no antibiotics. Notably, 75% of first-line and 63% of second-line antibiotics were prescribed for more than the recommended 7 days.
Axel A Vazquez Deida, PharmD, MPH, BCIDP, Health Scientist, Division of Healthcare Quality Promotion explains the most influential patient- and prescriber-level factors affecting guideline-concordant antibiotic prescribing for acute sinusitis were identified,
“We found that patients who reside in a rural area and receive care at an urgent care setting were less likely to receive an antibiotic prescription that was consistent with guideline recommendations for acute sinusitis. Those living in rural areas were 8% less likely to receive a recommended antibiotic and 23% less likely to receive a prescription for the recommended duration. Similarly, compared to office encounters, adults who sought care at an urgent care were 24% less likely to receive a prescription with the recommended duration.”
3 Key Takeaways
- Antibiotic prescribing for acute sinusitis varies widely, with only 53% of prescriptions meeting guideline recommendations and many extending beyond the recommended duration.
- Rural residents and those treated at urgent care facilities were less likely to receive antibiotics consistent with guidelines, with rural patients 8% less likely to get a recommended antibiotic and 23% less likely to receive it for the recommended duration.
- Targeted antibiotic stewardship is needed, especially in rural and urgent care settings, to reduce unnecessary use and ensure adherence to treatment guidelines, considering both patient demographics and healthcare settings.
Outpatient visits for adults aged 18 to 64 diagnosed with sinusitis between 2016 and 2020 were identified using national administrative claims data. Antibiotics were categorized into first-line (amoxicillin-clavulanate or amoxicillin) and second-line (doxycycline, levofloxacin, or moxifloxacin), with antibiotic courses of ≤7 days defined as guideline-concordant according to clinical practice guidelines. Modified Poisson regression was used to examine the relationship between patient- and prescriber-level factors and adherence to guideline-concordant antibiotic prescribing.
Antibiotics were classified as first-line or second-line based on clinical practice guidelines, and adherence to the recommended duration was assessed by comparing prescription lengths to these guidelines,
“Although amoxicillin is not considered a first-line agent by the IDSA (Infectious Diseases Society of America)guideline, it is recommended for the initial management of acute sinusitis by other clinical practice guidelines. Recent evidence has demonstrated that amoxicillin has similar efficacy to amoxicillin-clavulanate for adults with acute sinusitis and fewer gastrointestinal adverse events. Thus, amoxicillin was included among first-line agents for this analysis. Regarding duration, IDSA clinical practice guideline recommends 5 to 7 days of therapy for most adult patients with acute sinusitis, so we categorized antibiotic prescriptions with a day supply of 7 days or less as concordant with the guideline recommendations.”
This study has limitations, ICD-10 codes may misclassify the study population, and administrative claims lack details on infection severity. Dosing information was unavailable, affecting the assessment of guideline adherence. We did not exclude patients with recent sinusitis diagnoses, though this likely has minimal impact. Prescriber type and key factors such as race, income, and education were not included due to data limitations. The focus on commercially insured adults aged 18 to 64 may limit generalizability.
Moving Forward
The finding that a significant portion of antibiotics were prescribed for longer than recommended durations should inform future antibiotic stewardship efforts by emphasizing the need for stricter adherence to guideline-recommended treatment lengths,
“There is increasing evidence that shorter courses of antibiotic therapy are just as effective as longer courses for many common infections,” Deida emphasizes. “Our team found that antibiotic prescriptions for adults with acute sinusitis had a median duration of 10 days, with 75% of first-line agents and 63% of second-line agents being prescribed for more than 7 days.”
This finding underscores the need to tailor antibiotic stewardship efforts to encourage prescribing the shortest, most effective duration of therapy for adults with acute sinusitis. Clinicians and healthcare facilities should adhere to the CDC’s Core Elements of Outpatient Antibiotic Stewardship to optimize antibiotic selection and treatment duration, particularly in rural and urgent care settings.
Deida finalizes, “It is also important to note that in our study, only 17% of sinusitis encounters did not result in an antibiotic prescription. Since most cases of sinusitis have a viral cause, antibiotic therapy is often unnecessary for acute uncomplicated sinusitis. Therefore, antibiotic stewardship efforts should also focus on ensuring that antibiotics are prescribed only when needed. Delayed prescribing and watchful waiting are strategies that may help ensure that antibiotics are prescribed only when needed for acute sinusitis.”
In conclusion, antibiotic stewardship should be tailored to patient demographics, prescriber type, and outpatient settings to optimize prescribing and reduce unnecessary use and duration.
