By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
Dr. Deresinski reports no financial relationships relevant to this field of study.
SYNOPSIS: Clinicians inappropriately prescribe antibiotics most often to patients with a diagnosis of acute sinusitis for durations much longer than recommended.
SOURCE: King LM, Sanchez GV, Bartoces M, et al. Antibiotic therapy duration in US adults with sinusitis. JAMA Intern Med 2018;178:992-994.
Antibiotic therapy often is prescribed when it is unnecessary (and, therefore, by definition, more likely to be harmful than beneficial). Even when antibiotic therapy is appropriate, it often is administered for durations well beyond the time when its benefit has passed and only negative consequences remain, such as adverse reactions and continued unnecessary risk of selection of antibiotic resistance.
King et al have determined more precisely the actual practice of front-line clinicians regarding their prescribed duration of antibiotic therapy for patients with a diagnosis of acute sinusitis. The researchers examined the new antibiotic prescriptions for adults in association with a diagnosis of acute sinusitis in the 2016 National Disease and Therapeutic Index. They identified 3,696,976 visits meeting their criteria and found that the median duration of prescribed therapy was 10 days. Approximately two-thirds of antibiotics were prescribed for 10 days or longer.
Although azithromycin is administered most often for five days, its unusual pharmacokinetics with very slow elimination from tissues generally is considered to result in approximately 10 days of antibiotic exposure. A re-analysis of the data with removal of azithromycin from consideration found that, for the remaining prescribed antibiotics (80% of the total), an astounding 91.5% of prescriptions were for 10 days or longer. Furthermore, only 7.6% were for seven days, and 0.5% were for five days.
The most recent Infectious Diseases Society of America guideline (2012) recommends that for patients with a diagnosis of uncomplicated acute sinusitis who meet certain criteria (basically, severe or worsening illness or at least 10 days of symptoms), the duration of treatment should be five to seven days. Furthermore, the guideline recommends that macrolides, such as azithromycin, not be used for empiric therapy because of the high rate of resistance among pneumococci.
This study included prescriptions from a broad range of physician practitioners, including family practice, general practice, internal medicine, pediatrics, and emergency medicine. It documents what we already know: Physicians of all types often prescribe antibiotics for durations well in excess of the duration for which maximum benefit is achieved.
Implementing antimicrobial stewardship principles in the settings in which these therapies are prescribed is a critical element of the work ahead.