Inappropriate Antibiotics Still Given to Kids With Acute Sinusitis

December 28, 2010

By Megan Brooks

NEW YORK (Reuters Health) Dec 27 - A push to get US doctors to use amoxicillin in children with acute sinus inflammation appears to be paying off, a report published today in Pediatrics indicates.

"This is important," Dr. Adam L. Hersh, an author on the report, told Reuters Health, "because amoxicillin is effective while at the same time, inexpensive and narrow-spectrum. Using broad spectrum antibiotics when narrow-spectrum antibiotics are appropriate may promote drug resistance and increases costs."

That's the good news. The bad news is that inappropriate prescribing of more powerful antibiotics remains "common and unnecessary" in kids with acute sinusitis, the authors say.

The introduction in 2000 of a pneumococcal vaccine against otitis media was followed by a substantial decrease in the number of cases. And in 2004, the AAP recommended that amoxicillin become the first-line therapy for otitis media. The vaccine, and the 2004 recommendation, led to increased use of amoxicillin for this indication.

In 2001, the AAP had also recommended that amoxicillin be the first-line therapy for acute sinusitis. But had similar trends occurred in children with acute sinusitis following introduction of the vaccine and the advice to use amoxicillin first?

To find out, Dr. Hersh, from University of Utah in Salt Lake City, and colleagues at University of California, San Francisco examined time trends in doctor visits and antibiotic prescribing patterns between 1998 and 2007 for a nationally representative sample of 538 children with symptoms of acute sinusitis.

Unlike office visits for otitis media, visits for sinusitis did not fall after the vaccine was introduced, they report.

In the 10 years spanning 1998 to 2007, trips to the doctor for acute sinusitis held steady, ranging from 11 to 14 visits for every 1,000 children.

The researchers estimate that more than 8.9 million children saw a health care provider for acute sinusitis during the 10-year study period. This reflects an average of 895,000 visits each year.

"We were somewhat surprised," Dr. Hersh admitted, "that the office visit rate for acute sinusitis did not decline after the pneumococcal vaccine was introduced, as was seen for acute otitis media and pneumonia."

"Streptococcus pneumoniae, which is the bacteria targeted by this vaccine, is a frequent cause for all three of these conditions," he added. "That said, our study may not have had sufficient sample size to detect a change in the frequency of sinusitis visits, if one did indeed occur."

In a subset of 389 children, the researchers found that 82% left with a prescription for any antibiotic; this figure also held steady throughout the study period.

However, in accordance with the recommendations, the proportion who received amoxicillin rose during the study period - from 19% to 58%. Of note, the use of amoxicillin increased in the two years after the recommendations were issued, reversing an earlier trend of increased use of broad-spectrum agents.

What's concerning, however, is that prescriptions for the broader-spectrum antibiotics, especially macrolide antibiotics, remained common - 18% overall.

This does not jive with AAP recommendations, which suggest reserving broader-spectrum antibiotics - such as amoxicillin-clavulanate and cephalosporins - for very severe cases or for patients who failed previous antibiotic therapy. The stronger macrolide antibiotics - such as clarithromycin and azithromycin - are not routinely recommended for acute sinusitis.

Overall, the study team notes, there is mixed evidence for the effectiveness of antibiotics for acute sinusitis in children. Yet physicians routinely prescribe them for kids who show up with inflamed sinuses "and this practice has not changed in the past decade."

"Because of the continued tendency of physicians to prescribe antibiotics for treatment of acute sinusitis, this condition remains an important target for campaigns prompting judicious antibiotic use," they conclude.

"We need to continue to support efforts to promote judicious use of antibiotics," Dr. Hersh said. "Treatment guidelines from the AAP and campaigns such as the CDCs 'Get Smart - Know When Antibiotics Work' are very important in educating physicians and the public to ensure that antibiotics are used wisely," he added.


Pediatrics 2010.


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