September 2019 HSC Section 1 Congenital and Pediatric Problems

International Journal of Pediatric Otorhinolaryngology 108 (2018) 163–167

L. Newton et al.

studies that have reported antibiotic use in as many as 82 – 88% of pa- tient visits for rhinitis and nasal congestion symptoms [ 1 ]. Antibiotics are also the most common prescription drugs given to children, pre- dominantly 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 e ffi - cacy of antibiotics in viral infections and family physician's over- estimation 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 an- tibiotics than older patients (> 65 years) [ 1 ]. Nonclinical characteristics also signi fi cantly in fl uence use of anti- biotics 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 o ffi ce are bacterial in origin but as many as 30% may be so in a specialty o ffi ce [ 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 litera- ture for true ABRS. The American Academy of Pediatrics (AAP) re- commends penicillin as the fi rst-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) pa- tients. 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 bene fi cial adjunctive therapies for PCRS. While not speci fi cally discussed in the AAP guide- line, the PCRS clinical consensus statement does state that culture-di- rected antibiotics may improve outcomes for PCRS patients who have not responded to empiric antibiotic therapy [ 9 ].

providers (94 PCPs, 25 UC and 19 ENT) from 20 pediatric primary care clinics, 1 pediatric UC practice and 1 pediatric ENT practice, all asso- ciated with an academic medical center in a large urban city in the Midwest. Providers were de fi ned as physicians, advanced practice nurses and physician assistants. Participants had 3 weeks to complete the survey; responses were anonymous. This was a quality improve- ment project therefore IRB approval was waived. Survey questions were designed to assess how various practitioners approach the diagnosis and management of sinusitis. The survey began with an explanation of the terms used throughout the survey. The fol- lowing de fi nitions were provided to help guide survey responses:

2.1. Recurrent acute rhinosinusitis

Episodes of bacterial infection of the paranasal sinuses lasting fewer than 30 days and separated by intervals of at least 10 days during which the patient is asymptomatic. Some experts require at least 4 episodes in a calendar year to ful fi ll the criteria for this condition [ 10 ].

2.2. Chronic rhinosinusitis

At least 90 continuous days of 2 or more symptoms of purulent rhinorrhea, nasal obstruction, facial pressure/pain, or cough and either endoscopic signs of mucosal edema, purulent drainage, or nasal poly- posis and/or CT scan changes showing mucosal changes within the ostiomeatal complex and/or sinuses in a pediatric patient aged 18 years or younger [ 9 ]. Survey questions included the following topics: diagnostic criteria for sinusitis, if and when nasal culture is used in practice, antibiotic choice including length of therapy, use of adjuvant therapy, rationale for referral to ENT, and use of CT scan for sinusitis.

3. Results

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

3.1. Diagnosis

The diagnostic criteria for ABRS used most frequently by all pro- viders (95%) is persistent nasal drainage of any quality, day or night- time cough, or all of the above lasting more than 10 days without im- provement. Other diagnostic criteria used with slightly less frequency included symptoms of a classic viral URI with worsening of symptoms at day 5 – 7 (69.7%) and severe onset (concurrent fever) and purulent nasal discharge for at least 3 consecutive days (46.97%). Fig. 1 depicts these results. For patients with chronic or recurrent acute sinusitis, 78.6% of ENT providers, 19.4% of PCPs, and 5% of UC providers will culture these patients in the o ffi ce. The preferred method of ENT for obtaining nasal culture in o ffi ce is middle meatal culture with use of headlight or otoscope, with just one respondent reporting a preference to use in o ffi ce endoscopy for culture. Fifty-seven percent of ENT providers are comfortable with a nasal culture being obtained in the PCP's o ffi ce; however, 41.5% of PCPs and 30% of UC providers think that a patient should be seen by ENT for a nasal culture. One hundred percent of ENT providers feel that it is appropriate to obtain a nasal culture when a patient has been treated with several rounds of oral antibiotics from the ENT or PCP o ffi ce and returns with continued symptoms. Additionally, 71.4% of ENT providers responded that it was appropriate to culture new patients who present to clinic with symptoms of chronic rhinosi- nusitis and 57.1% of ENT providers would culture patients with per- sistent symptoms on an oral antibiotic before changing to another agent.

1.2. Study aim

The speci fi c aims of this descriptive, cross-sectional study were two- fold 1) To assess the perceived adherence of pediatric healthcare pro- viders 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).

2. 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 manage- ment of acute bacterial sinusitis, with a few questions addressing PCRS. The questionnaire was primarily multiple choice and took approxi- mately 20 min to complete. The survey was emailed to a total of 138

134