Spotlight Case April 2008

1. Spotlight Case April 2008 Antibiotics for URI/Sinusitis: A Simple Decision Gone Bad

2. Source and Credits • This presentation is based on the April 2008 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Sumant Ranji, MD, University of California, San Francisco School of Medicine • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Understand the indications for antibiotic treatment in acute sinusitis • Recognize the potential harms of inappropriate antibiotic prescribing for individual patients and the population at large • Review the evidence on the effectiveness of quality improvement efforts to reduce inappropriate antibiotic use

4. Case: Antibiotics for URI A healthy 53-year-old woman presented to her primary care physician with upper respiratory symptoms and possible sinusitis. She was prescribed Augmentin [amoxicillin- clavulanate]. Despite this therapy, her symptoms persisted. She was then prescribed azithromycin.

5. Upper Respiratory Tract Infections • Most common presenting complaint to PCPs • 83.1 million visits in 2002 • 3.1 million of these were acute sinusitis in adults • Sinusitis occurs after or in conjunction with a viral upper respiratory tract infection See Notes for references.

6. Acute Sinusitis • Most acute sinusitis caused by viruses • Only 0.5%-2% of viral sinusitis develops into a bacterial infection • Distinguishing viral from bacterial sinusitis on clinical grounds is difficult • Typical symptoms do not reliably predict which type • Imaging such as CT or X-ray can be abnormal in both viral and bacterial sinusitis Piccirillo JF. N Engl J Med. 2004;351:902-910.

7. CDC Recommendations • Acute bacterial rhinosinusitis can be diagnosed only when a patient has 3 clinical criteria: • Maxillary pain or tenderness in face or teeth • Mucopurulent nasal discharge • Symptoms have lasted for 7 days or more Hickner JM, et al. Ann Intern Med. 2001;134:498-505.

8. Additional Recommendations • Worsening of symptoms after initial improvement was moderately predictive of bacterial infection in some studies • Most bacterial sinusitis caused by Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis • Amoxicillin is preferred initial antibiotic recommended in guidelines from both CDC and American Academy of Otolaryngology–Head and Neck Surgery See Notes for references.

9. Over-treatment with Antibiotics • Despite guidelines, over-treatment with antibiotics is common • Prescribed in 82.7% of outpatient visits due to acute sinusitis in 2002 • Many of these prescriptions unnecessary • Vast majority of sinusitis is viral, especially when duration less than one week Sharp HJ, et al. Arch Otolaryngol Head Neck Surg. 2007;133:260-265.

10. Issues in Present Case • PCP should have examined for evidence of tenderness over maxillary sinuses • PCP should have asked patient about • Duration of symptoms • Character of nasal discharge • Presence of toothache • Treatment with amoxicillin reasonable had the 3 clinical criteria above been present

11. Issues in Present Case (cont.) • Patient was prescribed amoxicillin-clavulanate • This drug is second most common prescribed for acute sinusitis, but is generally not considered as first-line therapy • Azithromycin was then prescribed • A second course of antibiotics could only be justified if infection with a resistant organism was suspected • Even if antibiotics were warranted in this case, treatment should have been with amoxicillin and symptomatic therapies

12. Inappropriate Antibiotic Use • Amoxicillin-clavulanate and azithromycinare broad spectrum antibiotics • Neither known to be more effective in curing sinusitis than amoxicillin • Prescribing broad-spectrum agents when narrow-spectrum antibiotics are indicated is inappropriate • Use of broad-spectrum antibiotics rose in 1990s • For sinusitis, increased from less than 20% in 1991 to more than 40% in 1999 Steinman MA, et al. Ann Intern Med. 2003;138:525-533.

13. Case (cont.): Antibiotics for URI Shortly after starting her second course of antibiotics, the patient began feeling unwell. A few days later, she was found down in her home by her daughter. The patient was brought to the emergency department for evaluation. Her work up revealed profound anemia due to brisk autoimmune hemolysis. This was thought to be due to the amoxicillin-clavulanate she had received. She was started on high-dose immunosuppressive therapy with steroids.

14. Adverse Effects of Antibiotics • Common problems • Antibiotic-associated diarrhea • Rare, but dangerous reactions • Clostridium difficile colitis • Anaphylaxis • Autoimmune hemolysis

15. Antibiotics Confer Risks • Inappropriate use and overuse of antibiotics results in adverse effects for individuals and the population • Close link between antibiotic prescribing and antimicrobial resistance (AMR) • Worsening AMR in many bacteria, including: Staphylococcus aureus, Streptococcus pneumoniae, and Escherichia coli • Drug-resistant pathogens increasingly prevalent in the community • Infections with drug-resistant bacteria = increased morbidity, mortality, and health care expenditures Moellering RC Jr, et al. Am J Infect Control. 2007;35:S1-S23.

16. How Antibiotic Use Leads to Antimicrobial Resistance (AMR) • Creation of a susceptible host • By eliminating an individual's normal bacterial flora • Selective pressure • Promoting survival of bacterial strains with genetic mutations that confer antibiotic resistance Ranji SR, et al. In: AHRQ Publication No. 04-0051-4.

17. Combatting Antimicrobial Resistance (AMR) • National and international efforts aimed at reducing antibiotic prescription for conditions when not indicated • Major focus is decreasing antibiotic prescribing for acute respiratory infections, including sinusitis, since these infections are rarely bacterial in origin See Notes for references.

18. Case (cont.): Antibiotics for URI The patient’s hospital course was marked by multiorgan failure, septic shock, and spontaneous bowel perforation requiring hemicolectomy. Examination of the bowel showed Aspergillus, leading to a diagnosis of disseminated Aspergillosis. Despite aggressive antifungal therapy, the patient ultimately succumbed to overwhelming infection and died.

19. Aspergillus

20. What Happened? • In this case, the patient suffered a tragic outcome likely related to inappropriate prescribing of antibiotics • This patient’s complications and outcome are very rare • However, inappropriate antibiotic use remains common

21. Trends in Antibiotic Use • Over past decade, antibiotic prescribing for acute respiratory infections (ARIs) has decreased in response to publicity/education about AMR • However, prescribing rates for viral infections remain high—nearly half of adults with nonspecific ARIs prescribed antibiotics in 2002 • Limited success in reducing overall antibiotic prescribing possibly counteracted by increase in prescribing broad-spectrum antibiotics See Notes for references.

22. Deciding to Use Antibiotics • Patient factors • Often expect antibiotics to treat respiratory infections • Physician factors • Often use heuristics to judge if antibiotics are warranted, rather than relying on evidence-based criteria • Desire to respond to patient’s explicit (or implied) request for antibiotics See Notes for references.

23. Quality Improvement Efforts • Efforts to reduce inappropriate antibiotic prescribing and unnecessary broad-spectrum antibiotic use have been moderately effective • Promising strategies include: • Mass media campaigns in combination with targeted clinician education • Clinical decision support algorithms to indicate when antibiotic prescribing is appropriate See Notes for References.

24. Summary • Despite some successes, inappropriate antibiotic prescribing remains widespread • Failure to adhere to evidence-based treatment guidelines is increasingly being recognized as an error • Clinicians must take responsibility for improving their prescribing practices

25. Take-Home Points • Inappropriate antibiotic prescribing remains common, especially for acute respiratory infections • Clinicians should follow evidence-based treatment guidelines for sinusitis • Community-wide campaigns and clinical decision support systems show promise as means of addressing the overprescribing of antibiotics