Antibiotics to Treat Common Sinus Disorders

A program designed by the government of Quebec and several medical societies to educate physicians regarding the diagnosis and appropriate treatment for acute bacterial rhinosinusitis has led to a marked decrease in the use of antibiotics as a frontline therapy, at a time where antibiotic use for treatment of this common disorder rose significantly throughout the rest of Canada.

The effectiveness of the Quebec government initiative addresses a key problem in the medicine: overuse of antibiotics. The prescription of antibiotics can lead to antimicrobial resistance, or in other words, a decline in an antibiotics effectiveness in treating a bacterial disorder.

Acute bacterial rhinosinusitis, affecting some 4 million Canadians each year, is defined as bacterial infection of the paranasal sinuses and symptoms lasting up to four weeks. Symptoms include nasal discharge green or yellow in color, local pain in the sinus region, and the presence of pus in the nasal cavity.

Despite its prevalence, management of this disorder remains controversial. Antibiotics provide an earlier cure to the disorder but a majority of patients with this disorder recover without taking medications to kill the bacteria. Additionally, many believe that other disease and patient characteristics, such as age and duration and pattern of illness, may help identify which patients respond to more specific types of treatment.

This had led to the publication of more than 15 different guidelines addressing the antimicrobial treatment of acute rhinosinusitis since 2000. Despite the availability of these guidelines, there is little information regarding what impact these have on the prescribing habits of physicians, as this is generally not verified as part of the guidelines production process.

In January 2005, guidelines on the diagnosis and treatment of acute bacterial rhinosinusitis were distributed via mail to all physicians and pharmacists licensed in the province of Quebec, Canada. These guidelines were produced through a joint effort between a Quebec government agency and specialist associations for otolaryngology and infectious disease, and included recommendations for the diagnosis and management of acute rhinosinusitis, specifically selection of the appropriate antibiotic treatment and agent.

A public education campaign set out to inform the physicians to distinguish viral and bacterial acute rhinosinusitis and to restrict antibiotic treatment to cases where bacterial infection was judged to be present. The guidelines also addressed the choice of antibiotic to be used. Amoxicillin was recommended for first-line treatment and recommended second-line antibiotics were amoxicillin-clavulanate, cefuroxime, cefprozil, clarithromycin, gatifloxacin, levofloxacin and moxifloxacin. The goal of this outreach effort was to make physicians aware of acute bacterial rhinosinusitis guidelines and to reduce the use of antibiotics in their management of the disease.

How effectiveness was this government-physician specialist initiative? Two researchers set out to determinate whether these widely distributed acute bacterial rhinosinusitis guidelines affected the physicians prescription pattern and reduced antibiotics use for this common medical disorderacute rhinosinusitis.

The authors of Guidelines on the Diagnosis and Treatment of Acute Bacterial Rhinosinusitis in Quebec: Impact on Physicians Prescribing Pattern of Antibiotics, are Melanie Duval from McGill University, and Martin Desrosiers MD, affiliated with the Hotel-Dieu Hospital, Department of Otolaryngology, Université de Montréal, and Montreal General Hospital, Department of Otolaryngology, McGill University, all in Montreal, Quebec, Canada. Their findings were presented at the 110th annual meeting of the American Academy of OtolaryngologyHead and Neck Surgery Foundation, being held Sept. 17-20, 2006, at the Metro Toronto Convention Centre, Toronto, Canada.

The researchers obtained the IMS Health Canadian CompuScript, Canadian Disease and Therapeutic Index (CDTI) data on the antibiotics use for acute bacterial rhinosinusitis in Quebec for the three month period immediately following the distribution of the guidelines (February-April 2005) and the corresponding period the previous year (February-April 2004) for comparison purposes. Data for the corresponding periods were obtained for the rest of Canada, excluding the province of Quebec, in order to control for the year-to-year variability of the respiratory season.

The data is obtained from a representative sample of 652 of 45,800 office-based physicians stratified by specialty and geographic region. These physicians submit a case report book detailing the diagnosis made and the treatment recommended for all the patients seen over a 48 hours reporting period during each quarter. Data is then processed to obtain an estimate for the whole of Canada.

CompuScript, the second core database of the IMS Health Canada agency, provided a measure of prescriptions dispensed in Canadas pharmacies. Dispensing data was collected from electronic records gathered from 2,770 of the approximately 7,200 pharmacies in Canada. The selected pharmacies were representative of the universe of stores in Canada. Rates of prescriptions dispensed for acute sinusitis were estimated based on an extrapolation of CDTI ratios for drug mentions for ABRS to drug mentions all other diagnoses.

An overview of the number of antibiotic prescription filled for acute bacterial rhinosinusitis in Quebec and in Canada excluding Quebec before and after the distribution of the guidelines revealed that antibiotic prescriptions for acute bacterial rhinosinusitis decreased by 5.5 percent in Quebec, while there was a 30.1 percent increase in the rest of Canada excluding Quebec. However, while Quebec physicians did reduce antibiotic use, they did not increase their use of amoxicillin as first-line therapy.

The researchers believe that the guidelines were effective in changing physician behavior in treating acute bacterial rhinosinusitis because the format of the guidelines was concise, consisting of a full-page double-sided color card accompanied by a pocket-sized reference card; guideline distribution was uniform, reaching via mail all physicians and pharmacists licensed in the province of Quebec; and distribution of the guidelines was supported by a media campaign in order to raise the physicians, pharmacists and public awareness to their existence.

While the reduction in antibiotic prescriptions for treatment of this sinus disorder can be attributed to many causes. The findings reveal that widespread distribution of clinical guidelines via mailed material and a supporting media campaign may be an effective means of modifying physicians prescription habits. This approach could be highly effective in modifying the physicians behavior in the diagnosis and treatment of other medical disorders.

Source: American Academy of Otolaryngology, Head and Neck Surgery