Diagnosis and management of pediatric sinusitis: A survey of primary care, otolaryngology and urgent care providers

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Abstract

Objectives

The aims of this project were two-fold: 1) To assess pediatric primary care (PCP), pediatric otolaryngology (ENT) and pediatric urgent care (UC) providers' perception of their adherence to the 2013 American Academy of Pediatrics (AAP) established guidelines for the diagnosis and management of acute bacterial rhinosinusitis (ABRS) in children 1–18 years old and 2) to assess the same providers' practice patterns in the diagnosis and management of pediatric chronic rhinosinusitis (PCRS).

Method

A 21-item questionnaire (CVI .9) was designed by th investigators using Survey Monkey®. The survey was emailed to pediatric providers (including physicians and advanced practice providers) in a Midwestern USA healthcare system (94 PCP, 25 UC, 19 ENT providers) from 20 pediatric primary care practices, 1 pediatric UC practice and 1 pediatric otolaryngology practice.

Results

Diagnosis: The following diagnostic criteria are utilized: persistent nasal congestion/cough lasting >10 days (95%), worsening of classic viral URI symptoms at days 5–7 (70%), severe onset and purulent nasal discharge for at least 3 consecutive days (45%). ENT will most commonly culture their patients. ENT providers (57%) approve of a nasal culture being obtained by PCPs. Management: Typically used antibiotics: amoxicillin (72%), Amoxicillin-clavulanic acid (98%), cefdinir (73%), azithromycin (15%). ENT providers will also use clarithromycin and Bactrim more often compared to PCPs. For PCN allergy patients, most providers choose cefdinir. Typical length of antibiotic therapy for providers is 10 days (70%) and 14 days (17%); ENT (21%) prescribes 7 days past any symptom compared to PCP (6%) and UC (5%). Use of adjuvant therapy is variable among the groups.

Conclusion

This quality initiative project demonstrates that providers' diagnosis of ABRS is consistent with the 2013 AAP guidelines while variation in clinical management exists for both ABRS and PCRS. This survey demonstrates the need to educate all providers on the current 2013 AAP guidelines and define practice across all settings.

Introduction

Acute bacterial rhinosinusitis (ABRS) is one of the most common conditions treated by primary care providers with an estimated prevalence of 20 million cases of ABRS occurring annually in the United States [1]. ABRS is the fifth most common condition for which an antibiotic is prescribed in the US despite the fact that symptoms consistent with this diagnosis are self-limiting in the majority of patients within 2–4 weeks [2]. Because viral upper respiratory infection (URI) and ABRS can have overlapping symptoms, antibiotics are grossly overused for the former, resulting in consequences that may include allergic reactions, medication side effects, increasing antibiotic resistance and increasing healthcare costs [1,3]. Studies suggest that guidelines for the diagnosis and management of ABRS have not been effectively translated into routine practice [4]. More importantly, there is little research available to describe the adherence of pediatric providers to available guidelines for the management of ABRS in the pediatric population.

Despite strong guideline recommendations to restrict the use of antibiotics when treating viral URI, studies that have looked at adult populations have shown only a modest decrease in antibiotic prescription rates [2,5]. Pynnonen and colleagues [5], for example, reported that 69.9% of patients with mild symptoms of short duration in their study where prescribed an antibiotic. This is lower than previous studies that have reported antibiotic use in as many as 82–88% of patient visits for rhinitis and nasal congestion symptoms [1]. Antibiotics are also the most common prescription drugs given to children, predominantly in the ambulatory setting. An estimated 75% of antibiotic prescriptions are given to children for acute respiratory tract infections [6].

While there are multiple evidence-based guidelines published on the diagnosis and management of ABRS, over prescription and misuse of antibiotics around this diagnosis continues. Factors that contribute to the misuse of antibiotics include: patients' misconceptions on the efficacy of antibiotics in viral infections and family physician's overestimation of patients' expectations towards antibiotics [2,5]. Patients' expectations for antibiotic treatment may be as high as 70% [7]. In addition, younger patients (18–39 years old) tend to receive more antibiotics than older patients (>65 years) [1].

Nonclinical characteristics also significantly influence use of antibiotics for ABRS including the individual provider and the provider's specialty. For example, Pynnonen and colleagues [5] found that relative to internal medicine providers, emergency medicine providers used more antibiotics and family medicine providers used fewer antibiotics. Smith and colleagues [1] found that primary care providers prescribed antibiotics more frequently than ENT specialists. Even though less than 2% of sinusitis cases in a primary care office are bacterial in origin but as many as 30% may be so in a specialty office [7]. In addition, the presence of a medical trainee limited the use of antibiotics for ABRS [5].

In addition to the overuse of antibiotics for the treatment of viral URI, the misuse of broad spectrum antibiotics was noted in the literature for true ABRS. The American Academy of Pediatrics (AAP) recommends penicillin as the first-line agent for ABRS, streptococcal pharyngitis and pneumonia, yet roughly 50% of children receive broader-spectrum antibiotics for these common infections [3,6,8]. In the adult population, macrolides were the most prescribed antibiotic class for ABRS with an ENT specialist more likely to prescribe a broad-spectrum antibiotic more often than a primary care provider [1]. In the pediatric population, macrolides (primarily azithromycin) were the most commonly prescribed broad-spectrum antibiotics recommended [3].

A recent clinical consensus statement by Brietzke et al. [9] discussed medical management of pediatric chronic rhinosinusitis (PCRS) patients. The panel was able to reach consensus that 20 days of antibiotic treatment may result in a superior clinical response in PCRS patients compared to 10 days of antibiotics. They also agreed that daily topical nasal steroids and nasal saline irrigation are beneficial adjunctive therapies for PCRS. While not specifically discussed in the AAP guideline, the PCRS clinical consensus statement does state that culture-directed antibiotics may improve outcomes for PCRS patients who have not responded to empiric antibiotic therapy [9].

The specific aims of this descriptive, cross-sectional study were two-fold 1) To assess the perceived adherence of pediatric healthcare providers to the AAP 2013 established guidelines for the diagnosis and management of acute rhinosinusitis in children aged 1–18 years old; 2) To assess the same providers' practice patterns in the diagnosis and management of pediatric chronic rhinosinusitis (PCRS).

Section snippets

Material and methods

A 21-item questionnaire (CVI .9) was designed using Survey Monkey®. The questions were written by the investigators and based primarily on the AAP 2013 guidelines for the diagnosis and management of acute bacterial sinusitis, with a few questions addressing PCRS. The questionnaire was primarily multiple choice and took approximately 20 min to complete. The survey was emailed to a total of 138 providers (94 PCPs, 25 UC and 19 ENT) from 20 pediatric primary care clinics, 1 pediatric UC practice

Results

A total of 70 providers completed the survey (50.1% response rate).

Discussion

This quality improvement project demonstrates that providers' diagnostic criteria for ABRS are consistent amongst the three specialties and in accordance with the 2013 published AAP guidelines. However, there is some variation in clinical management between the three specialties, which is incongruent with the 2013 AAP guidelines. For example, the variation in length of antibiotic treatment is inconsistent with the 2013 AAP guidelines. While the guideline does mention that the optimal length of

Conclusion

Both within specialty areas and between the three specialties sampled, there is benefit for consistency in clinical management. Consistent diagnosis and management of rhinosinusitis will be easier for patients and families, as they know their child will be treated the same regardless of provider or location. Similar management strategies will also allow for consistent messaging from nursing and other support staff to families, decreasing potential confusion and dissatisfaction with treatment

Financial disclosures

None.

Conflicts of interest

None.

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