A response to the IDSA guidelines: Sinusitis is an extremely common condition resulting in patient suffering and frequent antibiotic use

TORONTO, March 29, 2012 /PRNewswire/ - The Infectious Diseases Society of America (IDSA) has recently published guidelines for acute sinusitis in adults and children. These evidence-based guidelines are similar in many respects to previously published guidelines, including the 2011 Canadian Clinical Practice Guidelines for Acute & Chronic Rhinosinusitis.

Acute bacterial rhinosinusitis (ABRS) is one of the most frequently encountered conditions in family medicine and it is a major driver of antibiotic consumption. ABRS accounts for an estimated 25% of all oral antibiotic therapy administered to adults. Identifying and disseminating appropriate management strategies is important not only for alleviating patient suffering, but also for reducing the emergence and spread of antibiotic resistance. Chronic rhinosinusitis is a frequent persistent disorder of the upper respiratory tract that can be responsible for prolonged disability and suffering in affected patients, even leading to surgery in patients resistant to medical therapy.

Remarks on the IDSA Guidelines
The IDSA guidelines represent a welcome addition to the existing set of guidelines and a useful complement that supports the importance of reducing antibiotic use for viral sinusitis. It addresses the risks of antimicrobial resistance and the rational use of antibiotic therapies. Guidelines for management of sinusitis in children are particularly useful as these have not been addressed in other guidelines.

The Canadian sinusitis guidelines effort are similar to most of these concepts, but differs in that even when acute bacterial rhinosinusitis is suspected, antibiotic therapy is given only in severe cases. In patients with mild/moderate symptoms antibiotics are offered as an option for supportive therapy only. This is supported by experimental evidence. Non-antibiotic treatment of suspected acute bacterial rhinosinusitis is the position that has been adopted by most recent guidelines. It is the consensus of The Canadian Rhinosinusitis Best Practices and Standards Working Group (RWG) that restricting antibiotic use in mild/moderate ABRS will, over time, result in significant reduction in overall antibiotic usage, with little or no impact on patient quality-of-life and will not lead to an increase in complications.

Advantages of the Canadian Guidelines are that they offer information and management strategies on chronic rhinosinusitis, a common disorder that has not been addressed by previous guidelines. The management strategies have taken into consideration the potential limited resources for specialist referral or specialized radiological imaging potentially possible in certain Canadian areas.

Comprehensive Education Program Launched:
The Canadian Rhinosinusitis Best Practices and Standards Working Group has conceived the guidelines as a component of a teaching program for general practitioners, with additional tools made readily available via a dedicated open-access website. Teaching tools include a video module on examination of the nose and sinuses, a self-assessment test on the sinusitis, downloadable algorithms in PDF format, and a slide kit intended for teaching purposes [see www.sinuscanada.com: password sinus].

As an additional innovation, these tools have been bundled into an "app" which will soon be available for distribution and use on various mobile platforms.  This was developed in response to the need to access information and images while assessing a patient in treatment or at consultation.

Adoption and implementation of the guidelines are also currently being monitored using various strategies to determine their impact on diagnosis, treatment, management and prescribing patterns. Information collected will help guide future policy decisions in this area and help improve subsequent versions of the sinus guidelines.

The Canadian Rhinosinusitis Best Practices and Standards Working Group
(comprises the Association of Medical Microbiology and Infectious Disease Canada; Canadian Association of Emergency Physicians; Canadian Society of Allergy and Clinical Immunology; Canadian Society of Otolaryngology - Head and Neck Surgery; and The Family Physicians Airway Group of Canada) shares the concerns of the ISDA Guideline authors and has devoted their efforts over the past 5 years to improving physician understanding and management of acute and chronic sinusitis One current goal in development is a patient advocacy platform that will provide access to up-to-date information on sinusitis for Canadians.

Principal author:  Martin Desrosiers, Otolaryngology - Montreal

Steering Committee:  Gerald A Evans, Infectious Diseases; Paul K Keith, Allergy and Clinical Immunology; Erin D Wright, Otolaryngology, Edmonton; Alan Kaplan, Family Medicine, Anthony Ciavarella, Family Medicine,; Patrick W Doyle, Medical Microbiology, Amin R Javer, Otolaryngology; Eric S. Leith, Allergy and Clinical Immunology; Atreyi Mukherji, Infectious Diseases, R Robert Schellenberg, Vancouver; Peter Small, Allergy and Clinical Immunology, Ian J Witterick, Otolaryngology

PRINCIPAL DIFFERENCES BETWEEN THE CANADIAN GUIDELINES AND THE IDSA GUIDELINES:

IDSA guidelines address the topic of acute rhinosinusitis in children: The IDSA guidelines address only the topic of acute rhinosinusitis, in both adults and children. The Canadian Clinical Practice Guidelines for Acute & Chronic Rhinosinusitis make recommendations only for the management of sinus disease in adults, thus the IDSA document may offer valuable guidance for the management of disease in children.

IDSA guideline does not cover the topic of chronic rhinosinusitis: Chronic rhinosinusitis is an increasingly frequent disorder of the upper airway. Despite important advances in our understanding of chronic rhinosinusitis over the past decade, many physicians remain uncertain how to diagnose and manage it, underlining the important educational need in this area. In order to help fill this knowledge gap, the Canadian Clinical Practice Guidelines for Acute & Chronic Rhinosinusitis offer evidence-based management strategies for diagnosis and appropriate management of the patient with chronic rhinosinusitis.

IDSA guidelines recommend antibiotic therapy for all cases of ABRS: The IDSA guidelines recommend antibiotic therapy in the management of all cases of suspected acute bacterial rhinosinusitis in adults. The Canadian guidelines, following a review of available evidence, suggest that antibiotics may not be required for all patients with suspected acute bacterial rhinosinusitis, and that antibiotics may safely be withheld in patients with only mild and moderate symptoms. Only patients with severe symptoms are recommended for routine antibiotic therapy.

Comment: The benefits of antibiotic therapy in routine management of suspected acute bacterial rhinosinusitis are questioned by several groups. It is well recognized that acute bacterial rhinosinusitis has a high rate of spontaneous resolution, and that antibiotic therapy has a minimal effect, at best, when compared to placebo in strictly controlled clinical trial settings. Given the potentially serious risks of antibiotic therapy directly to patients from complications such as colitis, or to society at large from the emergence of drug-resistant bacterial strains fueled by widespread use, the Canadian Rhinosinusitis Best Practices and Standards Working Group (RWG) has, in the interests of reducing overall antibiotic use, recommended a selective approach to antibiotic therapy in acute rhinosinusitis.

IDSA guidelines emphasize importance of addressing bacterial resistance in selection of first-line therapy where the endemic rate of penicillin-resistant Streptococcus pneumoniae is greater than 10%:  Antimicrobial resistance by bacterial organisms is an increasing area of concern, and inappropriate antimicrobial use is believed to be an important driver. In order to counter potential bacterial resistance to antibiotics, the IDSA guidelines recommend using augmented amoxicillin-clavulanate combinations over amoxicillin alone for uncomplicated suspected bacterial sinusitis where the endemic rate of penicillin-resistant Streptococcus pneumoniae is greater than 10%.

The 2011 Canadian guidelines recommend amoxicillin as a first-line therapy. This is appropriate as in Canada, overall resistance rates of Streptococcus pneumonia to amoxicillin, a semisynthetic penicillin antibiotic, is less than 3%, this resistance by Streptococcus pneumoniae to amoxicillin is not a concern and uncomplicated cases.

Both groups do however agree that selection of antibiotic therapy must be modified to take into account potential resistance in individuals with a higher risk of resistance. For individuals having taken antibiotics within the past 3 months, those with children in day care or individuals with a higher risk a failure from underlying chronic disease or involved sinuses (frontal and sphenoid), use of antibiotics with less concerns regarding resistance are recommended by both groups.

Choice of therapy for penicillin-allergic patients: In patients allergic to penicillin, Canadian guidelines recommend TMP/SMX or a macrolide antibiotic. The IDSA guidelines recommend doxycycline instead, suggesting a more favorable antibiotic resistance profile with this agent. In Canada, endemic antibiotic resistance rates for these 2 organisms are considerably lower than the United States, and we continue to believe that these remain acceptable alternatives to amoxicillin penicillin-allergic patients.

Recommendation against the use of topical decongestants: The IDSA guidelines recommend against the use of topical decongestants in acute sinusitis, offering some experimental evidence in support. It was the opinion of the expert group of the RWG that the positive impact of relieving nasal obstruction, particularly during sleep, outweighed any potential risk from short-term use.

Principal Similarities:

Despite these differences between to guidelines, there remain more similarities than differences.  These can be summarized as follows:

  • Similar diagnostic criteria for suspected acute bacterial rhinosinusitis

  • An agreement on the adjunct use of intranasal corticosteroids in the management of ABRS

  • The importance of early detection and treatment of complications of ABRS

SOURCE Red Roof Communications




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