September 2019 HSC Section 1 Congenital and Pediatric Problems

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

L. Newton et al.

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Halitosis with nasal congesƟon of any length of Ɵme

Persistent symptoms >10 days

Worsening of viral URI symptoms at days 5-7

Severe onset & purulent nasal discharge for 3 days

Fig. 1. The majority of providers diagnose sinusitis based on persistent nasal congestion/cough lasting > 10 days and/or worsening of viral URI symptoms at days 5 – 7.

after multiple (> 4) antibiotic treatment courses (100%), at parental request (73%), and for any suspected complication of sinusitis (82%). The majority of PCPs (72%) and UC providers (95%) are not routinely ordering a sinus CT. Forty percent of these providers will order a sinus CT only if they are worried about a complication of sinusitis. Fig. 4 describes reasons why PCPs and UC providers would order a CT scan for ABRS.

3.2. Management

The most commonly used antibiotics for ABRS or PCRS among all three groups are amoxicillin-clavulanic acid (97%), amoxicillin (73%) and cefdinir (70%). ENT providers more commonly use clarithromycin (43%) and TMP/SMX (29%) compared to PCPs and UC providers (11% and 6%, respectively). For patients with a non-type 1 penicillin allergy, the fi rst-line treatment of choice for acute or chronic sinusitis is cefdinir (88%). Fig. 2 depicts these results. The typical length of antibiotic therapy for ABRS prescribed by all providers is 10 days (70%) and 14 days (14%). ENT providers (21%) prescribes antibiotics to be taken for 7 days past any symptoms com- pared to PCPs (8%) and UC providers (5%). Only 4% of all respondents routinely recommend or give out safety net antibiotic prescriptions for upper respiratory infections in case symptoms worsen. The most common adjuvant therapy that is recommended for pa- tients with ABRS is nasal saline spray/irrigation (87%). ENT providers will also recommend use of topical Afrin (57%) compared to PCPs and UC providers (13%). These results are shown in Fig. 3 . Primary care and urgent care providers recommend referral to ENT for chronic or acute sinusitis if they have failed/are still symptomatic

4. Discussion

This quality improvement project demonstrates that providers' di- agnostic 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 antibiotic therapy for ABRS has not received systematic study, the authors mention an alternative suggestion that antibiotics be continued for 7 days past any symptoms [ 10 ]. Interest- ingly, in our sample, very few of the pediatricians practicing in primary

SinusiƟs Management: AnƟbioƟc Choice

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ENT PCP UC

Fig. 2. The most commonly used antibiotics are amoxicillin-clavulanic acid (97%), amoxicillin (73%), and cefdinir (70%).

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