Landmark sinusitis guidelines target antibiotic resistance

July 25, 2000

Guidelines provide new strategies to improve diagnosis, stop unnecessary antibiotic use and aid appropriate antibiotic selection for bacterial infections

New guidelines designed to address the alarming rise in bacterial resistance to antibiotics have been issued by The Sinus and Allergy Health Partnership*, with representation from the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA). The guidelines, published in the July issue of Otolaryngology-Head and Neck Surgery, were developed to stem antibiotic resistance by assisting health professionals to more accurately diagnose acute bacterial rhinosinusitis (ABRS), reduce the use of antibiotics for non-bacterial infections and recommend the use of the most effective antibiotics when ABRS is likely.

Because of the misuse and overuse of antibiotics to treat common conditions like sinusitis, resistance to many antibiotics in the most common bacterial causes of upper respiratory infections has risen to 40 to 50 percent in the last two decades. These guidelines are part of a national effort coordinated by the CDC, and supported by the Sinus and Allergy Health Partnership, aimed at educating health care practitioners and patients about curbing antibiotic resistance by reducing the overuse of antibiotics and improving antibiotic treatment when a bacterial infection is diagnosed. To assist health care practitioners, the guidelines analyze and rank 17 antibiotics commonly used to treat sinusitis according to their efficacy in fighting the bacteria that most often cause this condition. Sinusitis, the fifth most common diagnosis for which an antibiotic is prescribed, costs the United States economy nearly $3.5 billion dollars annually.

"Bacterial resistance to antibiotics is a growing public health threat to the United States," said Richard Besser, M.D., of the CDC's respiratory disease branch and one of the contributors to the new guidelines. "These guidelines are an important tool for physicians to begin to attack the problem of antibiotic resistance with more accurate diagnosis and appropriate antibiotic treatments. Just as important, we are working to educate the public about the personal and public health dangers that can result from the overuse and misuse of antibiotics for conditions like sinusitis."

Choosing the Right Drugs for the Right Bugs
To aid health care practitioners in selecting an antibiotic that is appropriate for the treatment of ABRS, the guidelines placed the most commonly used antibiotics into categories of expected clinical efficacy for the treatment of this condition. These categories are based on predicted efficacy rates in fighting the bacteria that most often cause ABRS -- Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis -- and a comparison of these rates to the rate at which bacterial infections resolve themselves without antibiotics.

"These guidelines are the first to rank predicted antibiotic efficacy in sinusitis, which is a major advance," said Michael R. Jacobs, MD, PhD, Professor, Department of Pathology, Case Western Reserve University and University Hospitals of Cleveland, Cleveland, Ohio, a clinical microbiologist who contributed to the guidelines. "Health professionals now have a rational basis for choosing first-line therapies, changing antibiotics if patients fail to respond to initial therapy, and selecting appropriate drugs for patients who recently received another antibiotic."

Is the Infection Bacterial?
To address the problem of overuse of antibiotics, the Partnership's guidelines provide diagnostic information to assist primary care physicians in distinguishing between a viral infection, which should not be treated with antibiotics, and ABRS, which requires treatment with an effective antibiotic, while addressing concerns caused by the rise in drug-resistant strains of bacteria. According to the guidelines, ABRS typically develops as a complication of nasal "allergies" or a viral respiratory infection, such as the common cold.

Symptoms of a viral infection or allergies may include sneezing, runny nose, nasal congestion, facial pressure, post-nasal drip, sore throat, cough and fever. The inflammation produced by these conditions prevents the normal drainage of fluids out of the sinuses, which can result in ABRS.

In general, a diagnosis of ABRS may be made in adults or children whose cold symptoms have not improved after 10 days or have worsened after five to seven days. It is important to note that a change in the color or characteristic of the nasal discharge is not a specific sign of a bacterial infection. Symptoms of an acute bacterial infection include nasal drainage, nasal congestion, facial pressure or pain, postnasal drainage, fever, cough, fatigue, dental pain and pressure in the ears.

"It is understandable in these busy times for patients suffering from a cold or nasal congestion to want immediate relief from an antibiotic and for physicians to want to please their patients," added Jack B. Anon, M.D., Associate Clinical Professor, Department of Otolaryngology, University of Pittsburgh College of Medicine and one of the contributors to the guidelines. "But this contributes to antibiotic resistance and ultimately can cause more, tough-to-treat infections. Physicians must counsel patients to treat cold's with medicines that will alleviate symptoms such as congestion and cough. Only when symptoms persist should an antibiotic be prescribed - and prescribed based on the drug's efficacy in fighting the bacteria that cause infections."

Sinusitis: A Serious and Prevalent Condition
There are approximately 20 million cases of ABRS reported each year in the United States. However, the number may be significantly higher because the symptoms of bacterial sinusitis often mimic those of colds or allergies, and many sufferers never see a doctor for proper diagnosis and treatment. ABRS is one of the most common conditions evaluated in the outpatient setting in North America. Sinusitis** accounts for 16 million physician office visits annually in the United States.
* The Sinus and Allergy Health Partnership is a not-for-profit organization created through the joint efforts of the American Academy of Otolaryngic Allergy, the American Academy of Otolaryngology - Head and Neck Surgery, and the American Rhinologic Society. The Partnership developed the sinusitis guidelines with representation from the CDC and the FDA and experts from the fields of infectious disease, pediatrics, pharmacy and microbiology.

**Refers to both chronic sinusitis and acute bacterial sinusitis.

Joe Fox

Megan Smith

Cohn & Wolfe

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