People with sinus infections stay on antibiotics too long

Most people prescribed antibiotics for sinus infections are on treatment courses of 10 days or longer even though infectious disease doctors recommend five to seven days for uncomplicated cases, a  study suggests.

Researchers examined data from a sample representing an estimated 3.7 million adults treated for sinusitis and prescribed antibiotics in 2016. Overall, 70 percent of antibiotics prescribed were for 10 days or longer, the study found.

“Any time antibiotics are used, they can cause side effects and lead to antibiotic resistance,” said senior study author.

“This is why it is so important to only use antibiotics when they are needed and to use the right antibiotic for the minimum effective duration,” the Dr. says
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Common side effects of antibiotics can include rash, dizziness, nausea, diarrhea and yeast infections, she said. More serious side effects may include life-threatening allergic reactions and Clostridium difficile infection, which causes diarrhea that can lead to severe colon damage and death.

Antibiotic resistance occurs when bacteria develop the ability to defeat the drugs designed to kill them and can make infections harder to treat.

When antibiotics are prescribed for sinus infections, only five to seven days of therapy are needed for uncomplicated cases, when patients start to recover within a few days of starting treatment and if they don’t have signs that the infection has spread beyond the sinuses, according to the researchers.

These guidelines are relatively new, however, and it’s possible some of the longer courses of antibiotics prescribed in the study occurred because not all doctors have absorbed the new practice recommendations, the Dr. said. Prior to 2012, the doctors recommended 10 to 14 days of antibiotics for sinus infections in adults.

In the study, no penicillin or tetracycline prescriptions were for five-day courses and only 5 percent of prescriptions were for seven-day courses of penicillins, tetracyclines or fluoroquinolones.

When researchers excluded azithromycin, an antibiotic that’s not recommended for sinus infections, they found that 91 percent of all antibiotic courses prescribed for sinus infections were for 10 days or longer.

The study didn’t examine whether or how the duration of antibiotics prescriptions impacted treatment of sinus infections or the potential for side effects.

Researchers also focused only on acute sinus infections, and by excluding some cases where the type of infection was unclear, they may have left out some acute cases, the study team notes.

It’s also possible that in some cases, doctors prescribed antibiotics for 10 days or longer and instructed patients to stop after five to seven days unless they were still experiencing symptoms, said a researcher, who wasn’t involved in the study.

One pitfall in this approach is that when patients improve slowly, it’s possible they’re infected with organisms that are resistant to the antibiotic they got prescribed, and they would recover faster if they switched to a different antibiotic instead of continuing the current one longer, the Dr. said by email.

“Older . . . acute bacterial sinusitis guidelines were written with the belief that if antibiotics were taken for shorter duration of time, that the bacteria would not be completely eradicated and that would risk persistent, recurrent and antibiotic resistant infections,” she said.

“But the recommendations have changed on this because subsequent studies have shown the opposite is true, that in fact if the patient is responding to treatment, five to seven days is safe and is usually enough,” she added. “A longer treatment is not usually needed.”

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Study links dental antibiotics to C diff cases

Antibiotics prescribed by dentists could be contributing to rising cases of Clostridium difficile, according to new research .

In a study conducted, researchers found that 15% of the patients diagnosed with community-associated C difficile infection (CA CDI) had been prescribed antibiotics for a dental procedure. And the authors of the study question how many of the prescriptions were necessary.

"Many of these prescriptions may not be meeting current prescribing guidelines," lead author and  epidemiologist  told reporters. "All prescribers, including dentists, should examine prescribing behavior for appropriateness."

CDI causes inflammation of the colon and severe, sometimes deadly diarrhea. The leading cause of healthcare-associated diarrhea and one of the most common healthcare-associated infections, CDI was responsible for nearly half a million infections and was associated with approximately 29,000 deaths in 2011. Cases of CDI most frequently occur in older patients who are taking antibiotics for other infections. The antibiotics disrupt the normal gut flora, wiping out both good and bad bacteria and allowing C difficile, a common environmental bacterium, to flourish in the intestinal tract.

Disconnect between medical and dental care

In the study, who perform regular surveillance for CDI , interviewed 1,626 people who had been diagnosed with CA CDI from 2009 through 2015. The cases were defined as CA CDI if the patients had not had an overnight stay in a hospital in the previous 12 weeks. Researcher said the majority of CDI cases occur outside the hospital and are driven by antibiotic use in community or outpatient settings.

Of the 1,626 patients, 926 (57%) had been prescribed an antibiotic, and 136 of those patients (15%) had been prescribed an antibiotic by their dentist. The patients who had received an antibiotic for a dental procedure were older than those prescribed antibiotics for other indications (57 years vs. 45 years) and were more likely to be prescribed clindamycin (50% vs. 10%), an antibiotic that causes diarrhea and has been associated with a higher risk of CDI.

The researchers also noted, however, that among the patients who had taken antibiotics for a dental procedure, more than a third (34%) had no mention of antibiotics in their medical chart. That finding, author said, highlights a disconnect between dental care and medical care; many patients aren't telling their doctors about drugs they've been prescribed for dental care, and dentists may not be warning patients about the potential side effects of antibiotic use.

"Better communication is needed between patients, dentists, and medical providers," author said. Patients should be sure to tell their primary care provider about any medications they are taking for dental reasons, and doctors should ask patients about dental visits and medication, and dentists should counsel patients about the risks of antibiotics.

Inappropriate antibiotic use in dentistry

According to the most recent estimates, dentists are responsible for roughly 10% of outpatient antibiotic prescriptions, writing more than 24.5 million prescriptions a year. Dentists most often prescribe antibiotics to treat oral infections caused by tooth abscesses, or prescribe them prophylactically to prevent infections in patients with heart conditions and artificial joints. But updated guidelines recommend prophylactic antibiotics only in a small number of patients with heart conditions, and not at all in patients with artificial joints.

In their interviews with a subset of the patients and reviews of their medical records, the  researchers found that nearly 10% didn't meet current  guidelines for receiving prophylactic antibiotics. In addition, author added, antibiotics may not be the best treatment for oral infections, either. She noted that under current recommendations, antibiotics aren't warranted for a tooth abscess in healthy individuals unless there are signs of systemic infection. Roughly 43% of the patients had received an antibiotic for an oral infection.

The website of the dentists says the organization supports responsible use of antibiotics to minimize the risk of adverse effects like CDI and the development of drug-resistant bacteria. But when they  surveyed dentists in 2015, they found that 36% prescribed antibiotics in situations generally not recommended by the association. In addition, fewer than half of the respondents said concerns about adverse effects influenced their prescribing.

Author said she has shared findings of the study with the  Dental Association, and that they are looking at ways to raise awareness of the issue and work with dentists to discuss barriers to appropriate prescribing. One of the problems is that while dentists are aware that CDI is a risk of antibiotic use, they aren't informed when their patients develop diarrhea and have to go to the doctor.  

"Dentists need to be included in antibiotic stewardship programs," author said. "They've often been overlooked, and it's absolutely critical that they are included to improve prescribing."

A professor of medicine  said the research is an important advance in the field, given the toll and costs of CDI. "The primary driver of Clostridium difficile is antibiotic use, and so the more we understand about how antibiotics are used, in which settings they are used, and how often they are used appropriately versus inappropriately, is incredibly important."

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