Management of acute maxillary sinusitis in Finnish primary care. Results from the nationwide MIKSTRA study

Nasal saline irrigation: prescribing habits and attitudes of physicians and pharmacists

OBJECTIVES

To explore the opinions, the usage and the patient education given on nasal saline irrigation by physicians and pharmaceutical personnel working in Finland.

DESIGN

An internet-based survey with predetermined, multiple-choice answers.

SETTING

Primary care centres, occupational health centres and private care centres in Eastern Finland as well as pharmacies in Finland.

MAIN OUTCOME MEASURES

Healthcare professionals views, practice and general knowledge of nasal irrigation for sinonasal symptoms and conditions.

RESULTS

We received 595 completed surveys (110 physicians, 485 pharmacists). The majority of the respondents recommended nasal saline irrigation for their patients either as a symptomatic treatment (98.0%) or to treat a specific condition (97.5%) such as acute rhinosinusitis, chronic rhinosinusitis and allergic rhinitis. Nasal saline irrigation was also often recommended as a prophylaxis for airway-infections (71.9%) and to enhance the health of the nasal mucosa (58.2%). In general, the possible adverse effects were recognised poorly by both professions. There was a clear difference between the two professions, as physicians were more conservative in recommending nasal saline irrigation and recognised possible adverse effects, such as epistaxis, pain, and dryness of the nose, better (75% vs. 59%, p = 0.002).

CONCLUSIONS

Nasal saline irrigation seems to be a popular treatment recommended by many health care professionals in Finland. Physicians and pharmaceutical personnel had variable opinions on the indications, utility and risks of nasal saline irrigation. There are also clear differences between physicians and pharmaceutical personnel's practices. There is a need to better educate professionals about nasal saline irrigation and to further study whether nasal saline irrigation is efficient and safe option for the different common sinonasal conditions.KEY POINTSLittle information is available on how physicians and pharmacists recommend nasal saline irrigation as a symptomatic treatment.Physicians and pharmacists seem to have variable opinions about the indications, utility and safety of nasal saline irrigation.The patient education given is in general very heterogenous.Both professions require more education to ensure that the usage remains as safe as possible for the patient.

Point-of-Care Sinus Ultrasound: Impact Within a Large Internal Medicine Clinic and Review of Technique

Outpatient diagnosis of acute bacterial sinusitis, using only traditional physical examination and clinical criteria, results in the overuse of antibiotics in patients with upper respiratory complaints. Point-of-care maxillary sinus ultrasound is easy to learn and quick to perform in a primary care clinic. The technique can reduce antibiotic prescribing by reassuring both patients and providers of the absence of fluid in the sinus, the hallmark of maxillary sinusitis. A review of the literature, description of technique, and results of sinus ultrasound implementation in a large internal medicine clinic are included.

A national approach to medicines information research: A systematic review

BACKGROUND

The Finnish Medicines Agency Fimea published the first National Medicines Information (MI) strategy in 2012. For the purpose of implementing the MI strategy into practice by the national MI Network, a comprehensive inventory of MI research in Finland was needed.

OBJECTIVE

To systematically review literature on MI research conducted in Finland by analyzing and classifying the studies, and identifying the gaps in MI research.

METHODS

Medline, Scopus and Medic databases were searched for peer-reviewed MI publications by using key word screening criteria. The search and extraction process followed PRISMA Guidelines and covered the period from January 2000 to June 2016. Included studies were content analyzed according to MI practices identified, trends over time in research methodology and theory.

RESULTS

Included publications (n = 126) applied a variety of research methods, most often cross-sectional surveys (n = 51, 40% of all studies), but more than half of the studies were qualitative (n = 68, 54%). Twelve were intervention studies of which 6 were randomized and had a control group. Studies were categorized into: patient counseling in different settings (n = 45); MI sources and needs of medicine users (n = 25); healthcare professionals' (HCPs) competence in patient counseling and pharmacotherapy (n = 25); MI sources and needs of HCPs (n = 23); MI education and literacy (n = 13); and MI policies and strategies (n = 3). Most of the studies were descriptive, and only 6 studies applied a theory.

CONCLUSIONS

Regardless of some methodological pitfalls, MI research conducted in Finland since 2000 provides multifaceted understanding of MI practices and their development needs. Research should shift towards larger research lines having a stronger theory base and study designs to deepen the understanding of MI practices and behaviors, and effectiveness of MI in different healthcare settings. Future research should cover also the use of electronic MI sources and services which apply modern information technology to clinical decision making and medication reviews, national MI policy, MI literacy, MI needs of HCPs and consumers.

Appropriateness of antibiotic prescribing for upper respiratory tract infections in general practice: Comparison between Denmark and Iceland

OBJECTIVE

To compare the appropriateness of antibiotic prescribing for upper respiratory tract infections (URTIs) in two countries with different prevalence of antimicrobial resistance: Denmark and Iceland.

DESIGN

A cross-sectional study.

SETTINGS AND SUBJECTS

General practitioners (GPs) in Denmark (n = 78) and Iceland (n = 21) registered all patients with URTI according to the Audit Project Odense (APO) method during a three-week period in the winter months of 2008 and 2009.

MAIN OUTCOME MEASURES

Appropriateness of antibiotic prescribing in patients with URTI in Denmark and Iceland.

RESULTS

A total of 1428 patients were registered (Denmark: n = 1208; Iceland: n = 220). A majority of patients in both countries were prescribed antibiotics, and only a minority of the prescriptions could be classified as appropriate prescribing. In general, Icelandic GPs more often prescribed antibiotics (Iceland = 75.8% vs. Denmark = 59.3%), but Danish GPs had a higher percentage of inappropriate antibiotic prescribing for sinusitis, and Icelandic GPs for pharyngotonsillitis. No differences were found for acute otitis media (AOM). The different antibiotic prescribing patterns between Denmark and Iceland could not fully be explained by different symptoms and signs among patients.

CONCLUSION

Icelandic GPs have a higher antibiotic prescribing rate compared with Danish GPs, but the percentage of inappropriate antibiotic prescribing is highest in Denmark for sinusitis, and in Iceland for pharyngotonsillitis. Key points Within the Nordic countries there are marked differences in antimicrobial resistance and antibiotic use. Iceland differs from Denmark by a higher antibiotic prescribing rate and a higher prevalence of antimicrobial resistance. The majority of antibiotics are prescribed in primary care and most often for upper respiratory infections (URTIs). Only a minor amount of antibiotic prescriptions for URTIs can be classified as appropriate; inappropriate antibiotic prescribing is higher in Denmark than in Iceland for sinusitis and the opposite for pharyngotonsillitis. The different antibiotic prescribing patterns between Denmark and Iceland cannot be fully explained by different clinical criteria among patients.

Anterior rhinoscopy and middle meatal culture in acute rhinosinusitis

Objective:

To assess the use of bacterial culture findings for middle meatal samples obtained via anterior rhinoscopy, in the diagnosis of adults with acute rhinosinusitis.

Materials and methods:

Microbial cultures were prepared for 30 adult patients with acute rhinosinusitis and suspected bacterial involvement, using samples from the nasopharynx, and from the nasal middle meatus obtained via anterior rhinoscopy. Findings for the ipsilateral maxillary antrum were used as a reference.

Results:

Seventeen patients had a bacterial infection as verified by a positive culture from the maxillary antrum. Middle meatal samples had a similar sensitivity but a better specificity, positive predictive value and negative predictive value, compared with nasopharyngeal samples, although predictive values were not statistically significant at a 95 per cent confidence level.

Conclusion:

Anterior rhinoscopy with culture of middle meatal samples can be recommended as a diagnostic procedure for acute rhinosinusitis. The results can also guide the decision on antibiotic treatment.

Antibiotic prescribing in patients with acute rhinosinusitis is not in agreement with European recommendations

OBJECTIVE

To assess the potential overprescribing in patients with acute rhinosinusitis across six countries with different antibiotic prescribing rates and different prevalence of antibiotic resistance.

DESIGN, SETTING AND SUBJECTS

A cross-sectional study including GPs from two Nordic countries, two Baltic countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) during three weeks in January 2008 as part of the EU-funded project "Health Alliance for Prudent Prescribing, Yield And Use of antimicrobial Drugs In the Treatment of respiratory tract infections" (HAPPY AUDIT).

MAIN OUTCOME MEASURES

Use of antibiotics for acute rhinosinusitis based on the recommendations in the European Position Paper on Rhinosinusitis and Nasal Polyps 2007 (EP3OS).

RESULTS

In total, 618 participating GPs registered 33 273 patients with RTI of whom 1150 (3.46%) were considered to have acute rhinosinusitis. Over 50% of the patients with acute rhinosinusitis had symptoms for < 5 days and 81% were prescribed antibiotics. In total, 68% of the patients included were not prescribed antibiotics according to guidelines; 45% had symptoms < 5 days or no fever (possible overprescribing) and 23% had symptoms < 5 days and no fever (probable overprescribing).

CONCLUSION

A considerable number of patients with symptoms of acute rhinosinusitis were not managed according to European recommendations (EP3OS guidelines). To prevent overprescribing, efforts should be made to implement the recommendations in daily practice.

Treatment of acute rhinosinusitis: discrepancy between guideline recommendations and clinical practice

BACKGROUND

A revised primary care guideline on acute rhinosinusitis (ARS) has been introduced in the Netherlands in 2005, which advocates a more judicious use of antibiotics.

OBJECTIVE

To investigate whether consultation and prescription rates for ARS in adults changed over recent years in order to provide information on family physicians' behaviour before and after introduction of the revised guideline.

METHODS

Retrospective cohort study. All adult patients within the computerized database of Utrecht Primary Care Research Network over the years 2000-09 were included. Clinical diagnoses of ARS were recorded according to the International Classification of Primary Care codes (R75 and/or R09) and drug prescriptions according to the Anatomical Therapeutic Chemical Classification System.

RESULTS

ARS consultation rates revealed a stable pattern, with an average consultation rate of 29 episodes per 1000 person-years. From 2000 to 2005, the antibiotic prescription rate increased from 56 to 62 prescriptions per 100 episodes (P value for time trend <0.05). From 2005 onwards, the antibiotic prescription rate decreased to 56 per 100 episodes in 2009 [rate difference (RD): -6, 95% confidence interval (CI): -10 to -1; P value for difference between 2000-05 and 2005-09 <0.05]. From 2005 to 2009, intranasal corticosteroid (INCS) prescription rate increased from 20 to 31 prescriptions per 100 episodes (RD: 11, 95% CI: 7 to 15; P value for difference between 2000-05 and 2005-09 <0.01). Oral corticosteroid prescription and referral rates remained low.

CONCLUSIONS

Despite strong guideline recommendations to restrict the use of antibiotics and INCS, we found only a modest decrease in antibiotic prescription rates, whereas INCS prescription rates even increased.

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults

Evidence-based guidelines for the diagnosis and initial management of suspected acute bacterial rhinosinusitis in adults and children were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America comprising clinicians and investigators representing internal medicine, pediatrics, emergency medicine, otolaryngology, public health, epidemiology, and adult and pediatric infectious disease specialties. Recommendations for diagnosis, laboratory investigation, and empiric antimicrobial and adjunctive therapy were developed.

Effectiveness of antibiotics for acute sinusitis in real-life medical practice

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Determining bacterial aetiology of acute sinusitis is difficult without employing invasive procedures. Most episodes of acute sinusitis resolve spontaneously. Antibiotics have demonstrated efficacy for the treatment of acute bacterial sinusitis in clinical trials yet little is known of their effectiveness in real-life treatment settings.

WHAT THIS STUDY ADDS

Most cases of untreated acute sinusitis resolved spontaneously. Antibiotics were more effective when given within the first 10 days of treatment. This had no effect on later recurrence. Patients with poor oro-dental condition or recent antibiotic use may derive the most benefit from an antibiotic prescription and this should be considered by prescribers. The antibiotics used were found to be equally effective. Existing recommendations to identify acute sinusitis with high probability of bacterial origin, such as the French recommendations, fever or duration of symptoms fail to identify patients in whom antibiotics are more effective.

AIMS

To assess the effectiveness of antibiotics in acute bacterial sinusitis.

METHODS

This was a prospective cohort study with 2 months follow-up of 5640 patients with acute sinusitis included by a random sample from 1174 GPs and 120 ENT specialists. Main outcomes were short-term initial success, defined as the absence of prescription of (another) antibiotic or sinus lavage within 10 days, and lack of recurrence between the 11th and 60th day, after initial success.

RESULTS

Initial success was found in 88.7% (95% CI 85.1, 91.4%) of patients without antibiotic prescription at inclusion and 96.2% (95% CI 95.7, 96.7%) of patients prescribed antibiotics. The 10 day adjusted hazard ratio (HR) for treatment failure (new antibiotic prescription or sinus drainage) with initial antibiotics compared with no antibiotics was 0.30 (95% CI 0.21, 0.42) with no difference between antibiotics. Antibiotics were more effective in patients with poor oro-dental condition (HR 0.04, 95% CI 0.01, 0.20) and in patients who had already used antibiotics during the previous 2 months (HR 0.09, 95% CI 0.03, 0.28). For patients without failure at 10 days, recurrence between the 11th and 60th day was similar whether or not they had initially been prescribed an antibiotic, 94.1% (95% CI 93.4, 94.7%) and 93.4% (95%CI 90.3, 95.5%), respectively.

CONCLUSION

Most acute sinusitis cases not prescribed antibiotics resolve spontaneously. Antibiotics reduced by 3.3-fold the risk of failure within 10 days, without impact on later recurrence. The greatest benefit of antibiotics was found for patients with poor oro-dental condition or with antibiotic use within the previous 2 months.

Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data

BACKGROUND

Primary-care physicians continue to overprescribe antibiotics for acute rhinosinusitis because distinction between viral and bacterial sinus infection is difficult. We undertook a meta-analysis of randomised trials based on individual patients' data to assess whether common signs and symptoms can be used to identify a subgroup of patients who benefit from antibiotics.

METHODS

We identified suitable trials--in which adult patients with rhinosinusitis-like complaints were randomly assigned to treatment with an antibiotic or a placebo--by searching the Cochrane Central Register of Controlled Trials, Medline, and Embase, and reference lists of reports describing such trials. Individual patients' data from 2547 adults in nine trials were checked and re-analysed. We assessed the overall effect of antibiotic treatment and the prognostic value of common signs and symptoms by the number needed to treat (NNT) with antibiotics to cure one additional patient.

FINDINGS

15 patients with rhinosinusitis-like complaints would have to be given antibiotics before an additional patient was cured (95% CI NNT[benefit] 7 to NNT[harm] 190). Patients with purulent discharge in the pharynx took longer to cure than those without this sign; the NNT was 8 patients with this sign before one additional patient was cured (95% CI NNT[benefit] 4 to NNT[harm] 47). Patients who were older, reported symptoms for longer, or reported more severe symptoms also took longer to cure but were no more likely to benefit from antibiotics than other patients.

INTERPRETATION

Common clinical signs and symptoms cannot identify patients with rhinosinusitis for whom treatment is clearly justified. Antibiotics are not justified even if a patient reports symptoms for longer than 7-10 days.

The Antimicrobial Treatment Strategies (MIKSTRA) Program: A 5-Year Follow-Up of Infection-Specific Antibiotic Use in Primary Health Care and the Effect of Implementation of Treatment Guidelines

BACKGROUND

A national 5-year follow-up study of infection-specific antibiotic use in primary care was conducted to see if prescribing practices change after implementing new treatment guidelines.

METHODS

The data were collected during 1 week of November each year from 1998 to 2002 from 30 health care centers that covered a total population of 819,777 persons and in 2002 from 20 control health care centers that covered a population of 545,098 persons. National guidelines for 6 major infections (otitis media, sinusitis, throat infection, acute bronchitis, urinary tract infection, and bacterial skin infection) were published in 1999-2000. Multifaceted interventions were performed by local trainers teaching his or her coworkers, supported by feedback and patient and public information.

RESULTS

The 6 infections targeted for intervention, together with unspecified upper respiratory tract infection constituted 80%-85% of all infections. The proportion of patients who received prescriptions for antibiotics did not change significantly. However, use of first-line antibiotics increased for all infections, and the change was significant for sinusitis (P<.001), acute bronchitis (P=.015), and urinary tract infections (P=.009). Also, the percentage of antibiotic treatments prescribed for the recommended duration increased significantly. Correct prescribing for respiratory tract infections improved by 6.4 percentage units (P<.001). However, there was no statistically significant difference in performance between study and control health care centers at follow-up.

CONCLUSIONS

Moderate qualitative improvements in antibiotic use were observed after multifaceted intervention, but prescribing for unjustified indications, mainly acute bronchitis, did not decrease. Obtained infection-specific information on management of patients with infections in primary health care is an important basis for planning targeted interventions in the future.

Cefuroxime axetil versus placebo for children with acute respiratory infection and imaging evidence of sinusitis: a randomized, controlled trial

AIM

To evaluate the efficacy of antibiotic treatment in children who presented in medical care with respiratory infection and had imaging evidence of sinusitis.

METHODS

Eighty-two children (4-10 y) with acute respiratory symptoms and ultrasonography findings suggestive of acute rhinosinusitis were enrolled in a randomized, double-blind trial. The sinus findings were confirmed with plain radiographs. The children received either cefuroxime axetil in 125-mg capsules twice a day for 10 d or placebo. Main outcome measures were complete cure in 2 wk and absence of prolonged symptoms or complications.

RESULTS

A total of 72 children (88%) completed follow-up. The sinusitis findings in the ultrasound could be confirmed with plain radiographs in 65 of the 72 patients (90%). The proportion of children completely cured by day 14 was similar in both groups (difference 6%, 95% confidence interval -16% to 29%). Similarly, there was no significant difference in the proportions of children who escaped prolonged disease and complications between the groups (difference 7%, -9% to 24%).

CONCLUSION

A 10-d course of cefuroxime axetil offered no clinical benefit to children with an acute respiratory illness and imaging evidence of acute sinusitis.