New York: A push to get US doctors to use the antibiotic amoxicillin in children with acute sinus inflammation appears to be paying off, a report published today in Pediatrics indicates.
That's the good news. The bad news is that inappropriate prescribing of other, more powerful antibiotics remains "common and unnecessary" in kids with sinus woes, the authors say.
Acute sinusitis is very common, accounting for more than 3 million doctor visits annually. Antibiotics are frequently prescribed for this condition. Beginning in 2001, the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) emphasized amoxicillin as the preferred antibiotic for most children with sinusitis.
The new report finds that these efforts have been successful in encouraging use of amoxicillin, instead of other more "broad-spectrum" antibiotics.
"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," Hersh explained.
Acute sinusitis often begins when a cold, which is caused by a virus, leads to inflammation in the lining of the sinuses. Colds can't be treated with antibiotics - but sometimes the inflammation leads to a bacterial infection. The bacteria Streptococcus pneumonia is a common cause of acute sinusitis and also of ear infections - what doctors call "otitis media." The two are considered similar diseases.
In 2000, a "pneumococcal" vaccine against otitis media was introduced, which was followed by a substantial decrease in the number of cases. And in 2004, the AAP recommended that amoxicillin be the "first-line therapy" for these ear infections (meaning that patients with otitis media should take amoxicillin before trying any other antibiotic). The vaccine, and the 2004 recommendation, led to increased use of amoxicillin for ear infections.
Back 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?
Dr. Hersh, from University of Utah in Salt Lake City, and colleagues at University of California, San Francisco addressed this question in their research. They 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; they ranged 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," 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 pneumonia, which is the bacteria targeted by this vaccine, is a frequent cause for all three of these conditions," he explained. "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, they note.
What's concerning, however, is that prescriptions for the "broader-spectrum" antibiotics (especially "macrolide" antibiotics), which attack a wider range of bacteria species, remained common - 18% overall.
This does not jive with AAP recommendations, which suggest reserving broader-spectrum antibiotics - such as amoxicillin-clavulanate and cephalosporins - for certain cases, such as people with very severe cases or those who have 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," 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.
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