National burden of antibiotic use for adult rhinosinusitis

Abstract

Rhinosinusitis (RS) is among the most common conditions encountered in medicine, affecting approximately 15% of the adult population annually.1Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.European position paper on rhinosinusitis and nasal polyps 2012.Rhinology. 2012; 50: 1-307Crossref PubMed Google Scholar, 2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar According to major consensus guidelines, antibiotics are not recommended for most patients with uncomplicated cases of acute RS (ARS).1Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.European position paper on rhinosinusitis and nasal polyps 2012.Rhinology. 2012; 50: 1-307Crossref PubMed Google Scholar, 2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar, 3Rosenfeld R.M. Andes D. Bhattacharyya N. Cheung D. Eisenberg S. Ganiats T.G. et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Scopus (661) Google Scholar, 4Choosing wisely. Philadelphia: ABIM Foundation. Available from: http://www.choosingwisely.org/. Accessed August 5, 2013.Google Scholar, 5Chow A.W. Benninger M.S. Brook I. Brozek J.L. Goldstein E.J. Hicks L.A. et al.IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults.Clin Infect Dis. 2012; 54: e72-e112Crossref PubMed Scopus (447) Google Scholar The role of antibiotics for chronic RS (CRS) is controversial,2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar and recent authors recommend that objective evidence by endoscopy or computed tomography should be obtained if a prolonged course of antibiotics is to be given for CRS.6Ferguson B.J. Narita M. Yu V.L. Wagener M.M. Gwaltney Jr., J.M. Prospective observational study of chronic rhinosinusitis: environmental triggers and antibiotic implications.Clin Infect Dis. 2012; 54: 62-68Crossref PubMed Scopus (37) Google Scholar However, previous studies show that antibiotics are prescribed extensively to treat RS, in approximately more than 80% of ARS7Smith S.S. Kern R.C. Chandra R.K. Tan B.K. Evans C.T. Variations in antibiotic prescribing of acute rhinosinusitis in United States ambulatory settings.Otolaryngol Head Neck Surg. 2013; 148: 852-859Crossref PubMed Scopus (38) Google Scholar and 50% of CRS8Lee L.N. Bhattacharyya N. Regional and specialty variations in the treatment of chronic rhinosinusitis.Laryngoscope. 2011; 121: 1092-1097Crossref PubMed Scopus (32) Google Scholar patient visits.Excessive antibiotic use is associated with consequences including allergic reactions, adverse effects, unnecessary costs, and increasing bacterial resistance. With the clinical and economic tolls of inappropriate antibiotic prescribing in mind, the goal of this study was to perform a contemporary analysis of the overall antibiotic burden of RS on a national level.We analyzed data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey Outpatient Department component from 2006 to 2010. These surveys are conducted annually by the US Department of Health and Human Services to provide data from a national sample of outpatient visits. These data are weighted to produce national estimates that describe the use of ambulatory medical care services in the United States.We identified visits by adults aged 18 years or older in which an antibiotic was prescribed (antibiotic visits). The total number and percentage of primary diagnoses, identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code, associated with each antibiotic visit were tabulated. Primary diagnoses commonly grouped together9McCaig L.F. Hughes J.M. Trends in antimicrobial drug prescribing among office-based physicians in the United States.JAMA. 1995; 273: 214-219Crossref PubMed Scopus (742) Google Scholar were also analyzed in groups. The number and percentage of antibiotic visits associated with a primary diagnosis of ARS (ICD-9-CM 461.x) and CRS (ICD-9-CM 471.x or 473.x) were tabulated. Statistical analyses were performed by using STATA (version 12.0; STATA Corp, College Station, Tex). Descriptive data are presented as mean with 95% CIs. Accounting for the survey's sampling design, statistics were derived by a multistage estimation procedure designed by the National Center for Health Statistics to produce essentially unbiased national estimates: (1) inflation by reciprocals of the probabilities of selection, (2) adjustment for nonresponse, (3) a ratio adjustment to fixed totals, and (4) weight smoothing.10National Center for Health Statistics NAMCS micro-data file documentation. US Department of Health and Human Services, Public Health Services, Centers for Disease Control and Prevention, Hyattsville, Md2006Google ScholarOver the 5-year study period, there were 21.4 million (95% CI, 17.2-25.7 million) estimated visits associated with a primary diagnosis of ARS and 47.9 million (95% CI, 41.2-54.7 million) estimated visits associated with a primary diagnosis of CRS. Overall, antibiotics were prescribed in 85.5% (95% CI, 80.7%-89.2%) of ARS visits and 69.3% (95% CI, 64.8%-73.5%) of CRS visits.Over the 5-year study period, RS (ARS and CRS combined) accounted for 11.0% (95% CI, 10.0%-12.1%) of all primary diagnoses for ambulatory care visits with antibiotic prescriptions, more than any other diagnosis or commonly grouped diagnoses (Fig 1). When comparing individual diagnoses, a primary diagnosis of unspecified CRS (ICD-9 473.x) accounted for 7.1% (95% CI, 6.2%-8.0%) of antibiotic visits, still more than any other primary diagnosis. Analyses by individual year are presented in Table I. There was no significant linear time trend in overall antibiotic burden in RS groups (P = .98 for all RS, P = .16 for CRS, P = .19 for ARS). Because CRS with nasal polyps may be coded as 473.x (CRS) and 471.x (nasal polyp), we have shown that a diagnosis of nasal polyp did not make a meaningful contribution to the overall antibiotic burden of RS (Table I). In 2010, unspecified CRS (ICD-9 473.x) accounted for 5.57% of antibiotic visits and ranked second to unspecified urinary tract infection, which accounted for 5.59% of antibiotic visits.Table IPercentage of outpatient visits with antibiotic prescriptions attributed to RS diagnosesRS Total % (rank∗Rank among all primary diagnoses or commonly grouped diagnoses for receipt of an antibiotic.)CRS % (rank∗Rank among all primary diagnoses or commonly grouped diagnoses for receipt of an antibiotic.)ARS %Nasal polyps200611.6 (1)7.8 (1)3.70.0620079.6 (1)7.1 (1)2.5<0.01200812.2 (1)8.2 (1)4.00.03200910.7 (1)6.9 (1)3.70.03201011.0 (1)5.6 (2)5.40.01Combined years, 2006-201011.0 (1)7.1 (1)3.90.03∗ Rank among all primary diagnoses or commonly grouped diagnoses for receipt of an antibiotic. Open table in a new tab The most commonly prescribed antibiotic classes at CRS visits were penicillins/betalactams, followed by macrolides, and then quinolones (33.0% [95% CI, 26.3%-41.2%], 25.6% [95% CI, 21.3%-30.4%], and 18.6% [95% CI, 15.0%-22.8%], respectively). The most commonly prescribed antibiotic classes at ARS visits were penicillins/betalactams, followed by macrolides, and then quinolones (54.4% [95% CI, 39.5%-73.7%], 28.7% [95% CI, 22.7%-35.4%], and 19.9% [95% CI, 15.7%-25.0%], respectively).This study demonstrates that RS accounts for more outpatient antibiotic prescriptions than any other diagnosis, identifying RS as a major target in national efforts to reduce unnecessary medical intervention. The proportion of outpatient antibiotics attributed to RS did not decrease following the release of American Academy of Otolaryngology-Head & Neck Surgery Clinical Practice Guidelines released in September 2007 (Table I).3Rosenfeld R.M. Andes D. Bhattacharyya N. Cheung D. Eisenberg S. Ganiats T.G. et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Scopus (661) Google Scholar In 2010, the proportion of all antibiotics associated with CRS diagnosis 473.x dropped but the proportion of all antibiotics associated with the ARS diagnosis increased; future data will tell whether these changes represent fluctuations or a trend.A study published in 1995 by McCaig and Hughs9McCaig L.F. Hughes J.M. Trends in antimicrobial drug prescribing among office-based physicians in the United States.JAMA. 1995; 273: 214-219Crossref PubMed Scopus (742) Google Scholar identified sinusitis as the fifth most common diagnosis associated with antibiotic prescriptions, and this figure is cited frequently in mass media and scientific literature, including major consensus guidelines.1Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.European position paper on rhinosinusitis and nasal polyps 2012.Rhinology. 2012; 50: 1-307Crossref PubMed Google Scholar, 3Rosenfeld R.M. Andes D. Bhattacharyya N. Cheung D. Eisenberg S. Ganiats T.G. et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Scopus (661) Google Scholar Their study used National Ambulatory Medical Care Survey data, but differs from our study because it included children and excluded fluoroquinolones and macrolides.9McCaig L.F. Hughes J.M. Trends in antimicrobial drug prescribing among office-based physicians in the United States.JAMA. 1995; 273: 214-219Crossref PubMed Scopus (742) Google Scholar The increased burden of antibiotics accounted for by RS in our study likely reflects these differences in methodology but may also reflect reduced antibiotic use for other diagnoses and reflexive increase in the proportion of antibiotics attributed to RS; such a determination is outside the scope of this study.Physicians prescribed antibiotics in the vast majority of ARS and CRS visits in this study. Major consensus guidelines recommend against antibiotic treatment for uncomplicated mild ARS,1Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.European position paper on rhinosinusitis and nasal polyps 2012.Rhinology. 2012; 50: 1-307Crossref PubMed Google Scholar, 2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar, 3Rosenfeld R.M. Andes D. Bhattacharyya N. Cheung D. Eisenberg S. Ganiats T.G. et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Scopus (661) Google Scholar, 4Choosing wisely. Philadelphia: ABIM Foundation. Available from: http://www.choosingwisely.org/. Accessed August 5, 2013.Google Scholar, 5Chow A.W. Benninger M.S. Brook I. Brozek J.L. Goldstein E.J. Hicks L.A. et al.IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults.Clin Infect Dis. 2012; 54: e72-e112Crossref PubMed Scopus (447) Google Scholar and the role of antibiotics in CRS is controversial.2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar According to the 2005 Joint Task Force on Practice Parameters guidelines, antibiotics may be useful for acute exacerbation of chronic disease.2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar However, there are no placebo-controlled trials regarding short-term antibiotic treatment of CRS without nasal polyps, but there is some evidence supporting long-term, low-dose macrolide antibiotics for 12 weeks for patients with CRS.1Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.European position paper on rhinosinusitis and nasal polyps 2012.Rhinology. 2012; 50: 1-307Crossref PubMed Google Scholar The 2012 European Position Paper on Rhinosinusitis and Nasal Polyps guidelines recommend initial long-term macrolide therapy for moderate/severe cases of CRS without nasal polyps. In our study, CRS was associated most frequently with penicillins/betalactams, followed by macrolides. Lee and Bhattacharyya8Lee L.N. Bhattacharyya N. Regional and specialty variations in the treatment of chronic rhinosinusitis.Laryngoscope. 2011; 121: 1092-1097Crossref PubMed Scopus (32) Google Scholar showed that amoxicillin and azithromycin were the most commonly prescribed antibiotics for CRS diagnoses in 2005-2006, with variations by region and physician specialty. They propose that a lack of evidence regarding CRS treatment may lead physicians to broadly prescribe medications without improving patient care or outcomes.8Lee L.N. Bhattacharyya N. Regional and specialty variations in the treatment of chronic rhinosinusitis.Laryngoscope. 2011; 121: 1092-1097Crossref PubMed Scopus (32) Google Scholar Ferguson et al suggest that objective evidence by endoscopy or computed tomography should be obtained if antibiotics are to be given for a prolonged duration, recommending a “moratorium for the widespread practice of a prolonged course of empiric antibiotics in patients with presumed CRS.”6Ferguson B.J. Narita M. Yu V.L. Wagener M.M. Gwaltney Jr., J.M. Prospective observational study of chronic rhinosinusitis: environmental triggers and antibiotic implications.Clin Infect Dis. 2012; 54: 62-68Crossref PubMed Scopus (37) Google Scholar Nevertheless, it is apparent that antibiotics are prescribed frequently for ARS and CRS.Our study relies on ICD-9 coding in a national database, and limitations include inability to reliably parse ARS from CRS and acute bronchitis from chronic bronchitis. Therefore, we present data based on individual ICD-9 codes, as well as combined codes for all forms of RS and forms of bronchitis (Fig 1). Inclusion of ARS along with CRS ICD-9 diagnoses ensures capture of all RS visits, including acute exacerbations of CRS that may be coded as ARS.Failure to adhere to recommended antibiotic treatment guidelines remains a significant issue in RS. Thus, current treatment recommendations should be promoted across specialties, and efforts to educate policymakers and the general public on the indications, benefits, and risks of antibiotics should be increased. This should be of high relevance to policymakers, patients, and clinicians. Rhinosinusitis (RS) is among the most common conditions encountered in medicine, affecting approximately 15% of the adult population annually.1Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.European position paper on rhinosinusitis and nasal polyps 2012.Rhinology. 2012; 50: 1-307Crossref PubMed Google Scholar, 2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar According to major consensus guidelines, antibiotics are not recommended for most patients with uncomplicated cases of acute RS (ARS).1Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.European position paper on rhinosinusitis and nasal polyps 2012.Rhinology. 2012; 50: 1-307Crossref PubMed Google Scholar, 2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar, 3Rosenfeld R.M. Andes D. Bhattacharyya N. Cheung D. Eisenberg S. Ganiats T.G. et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Scopus (661) Google Scholar, 4Choosing wisely. Philadelphia: ABIM Foundation. Available from: http://www.choosingwisely.org/. Accessed August 5, 2013.Google Scholar, 5Chow A.W. Benninger M.S. Brook I. Brozek J.L. Goldstein E.J. Hicks L.A. et al.IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults.Clin Infect Dis. 2012; 54: e72-e112Crossref PubMed Scopus (447) Google Scholar The role of antibiotics for chronic RS (CRS) is controversial,2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar and recent authors recommend that objective evidence by endoscopy or computed tomography should be obtained if a prolonged course of antibiotics is to be given for CRS.6Ferguson B.J. Narita M. Yu V.L. Wagener M.M. Gwaltney Jr., J.M. Prospective observational study of chronic rhinosinusitis: environmental triggers and antibiotic implications.Clin Infect Dis. 2012; 54: 62-68Crossref PubMed Scopus (37) Google Scholar However, previous studies show that antibiotics are prescribed extensively to treat RS, in approximately more than 80% of ARS7Smith S.S. Kern R.C. Chandra R.K. Tan B.K. Evans C.T. Variations in antibiotic prescribing of acute rhinosinusitis in United States ambulatory settings.Otolaryngol Head Neck Surg. 2013; 148: 852-859Crossref PubMed Scopus (38) Google Scholar and 50% of CRS8Lee L.N. Bhattacharyya N. Regional and specialty variations in the treatment of chronic rhinosinusitis.Laryngoscope. 2011; 121: 1092-1097Crossref PubMed Scopus (32) Google Scholar patient visits. Excessive antibiotic use is associated with consequences including allergic reactions, adverse effects, unnecessary costs, and increasing bacterial resistance. With the clinical and economic tolls of inappropriate antibiotic prescribing in mind, the goal of this study was to perform a contemporary analysis of the overall antibiotic burden of RS on a national level. We analyzed data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey Outpatient Department component from 2006 to 2010. These surveys are conducted annually by the US Department of Health and Human Services to provide data from a national sample of outpatient visits. These data are weighted to produce national estimates that describe the use of ambulatory medical care services in the United States. We identified visits by adults aged 18 years or older in which an antibiotic was prescribed (antibiotic visits). The total number and percentage of primary diagnoses, identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code, associated with each antibiotic visit were tabulated. Primary diagnoses commonly grouped together9McCaig L.F. Hughes J.M. Trends in antimicrobial drug prescribing among office-based physicians in the United States.JAMA. 1995; 273: 214-219Crossref PubMed Scopus (742) Google Scholar were also analyzed in groups. The number and percentage of antibiotic visits associated with a primary diagnosis of ARS (ICD-9-CM 461.x) and CRS (ICD-9-CM 471.x or 473.x) were tabulated. Statistical analyses were performed by using STATA (version 12.0; STATA Corp, College Station, Tex). Descriptive data are presented as mean with 95% CIs. Accounting for the survey's sampling design, statistics were derived by a multistage estimation procedure designed by the National Center for Health Statistics to produce essentially unbiased national estimates: (1) inflation by reciprocals of the probabilities of selection, (2) adjustment for nonresponse, (3) a ratio adjustment to fixed totals, and (4) weight smoothing.10National Center for Health Statistics NAMCS micro-data file documentation. US Department of Health and Human Services, Public Health Services, Centers for Disease Control and Prevention, Hyattsville, Md2006Google Scholar Over the 5-year study period, there were 21.4 million (95% CI, 17.2-25.7 million) estimated visits associated with a primary diagnosis of ARS and 47.9 million (95% CI, 41.2-54.7 million) estimated visits associated with a primary diagnosis of CRS. Overall, antibiotics were prescribed in 85.5% (95% CI, 80.7%-89.2%) of ARS visits and 69.3% (95% CI, 64.8%-73.5%) of CRS visits. Over the 5-year study period, RS (ARS and CRS combined) accounted for 11.0% (95% CI, 10.0%-12.1%) of all primary diagnoses for ambulatory care visits with antibiotic prescriptions, more than any other diagnosis or commonly grouped diagnoses (Fig 1). When comparing individual diagnoses, a primary diagnosis of unspecified CRS (ICD-9 473.x) accounted for 7.1% (95% CI, 6.2%-8.0%) of antibiotic visits, still more than any other primary diagnosis. Analyses by individual year are presented in Table I. There was no significant linear time trend in overall antibiotic burden in RS groups (P = .98 for all RS, P = .16 for CRS, P = .19 for ARS). Because CRS with nasal polyps may be coded as 473.x (CRS) and 471.x (nasal polyp), we have shown that a diagnosis of nasal polyp did not make a meaningful contribution to the overall antibiotic burden of RS (Table I). In 2010, unspecified CRS (ICD-9 473.x) accounted for 5.57% of antibiotic visits and ranked second to unspecified urinary tract infection, which accounted for 5.59% of antibiotic visits. The most commonly prescribed antibiotic classes at CRS visits were penicillins/betalactams, followed by macrolides, and then quinolones (33.0% [95% CI, 26.3%-41.2%], 25.6% [95% CI, 21.3%-30.4%], and 18.6% [95% CI, 15.0%-22.8%], respectively). The most commonly prescribed antibiotic classes at ARS visits were penicillins/betalactams, followed by macrolides, and then quinolones (54.4% [95% CI, 39.5%-73.7%], 28.7% [95% CI, 22.7%-35.4%], and 19.9% [95% CI, 15.7%-25.0%], respectively). This study demonstrates that RS accounts for more outpatient antibiotic prescriptions than any other diagnosis, identifying RS as a major target in national efforts to reduce unnecessary medical intervention. The proportion of outpatient antibiotics attributed to RS did not decrease following the release of American Academy of Otolaryngology-Head & Neck Surgery Clinical Practice Guidelines released in September 2007 (Table I).3Rosenfeld R.M. Andes D. Bhattacharyya N. Cheung D. Eisenberg S. Ganiats T.G. et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Scopus (661) Google Scholar In 2010, the proportion of all antibiotics associated with CRS diagnosis 473.x dropped but the proportion of all antibiotics associated with the ARS diagnosis increased; future data will tell whether these changes represent fluctuations or a trend. A study published in 1995 by McCaig and Hughs9McCaig L.F. Hughes J.M. Trends in antimicrobial drug prescribing among office-based physicians in the United States.JAMA. 1995; 273: 214-219Crossref PubMed Scopus (742) Google Scholar identified sinusitis as the fifth most common diagnosis associated with antibiotic prescriptions, and this figure is cited frequently in mass media and scientific literature, including major consensus guidelines.1Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.European position paper on rhinosinusitis and nasal polyps 2012.Rhinology. 2012; 50: 1-307Crossref PubMed Google Scholar, 3Rosenfeld R.M. Andes D. Bhattacharyya N. Cheung D. Eisenberg S. Ganiats T.G. et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Scopus (661) Google Scholar Their study used National Ambulatory Medical Care Survey data, but differs from our study because it included children and excluded fluoroquinolones and macrolides.9McCaig L.F. Hughes J.M. Trends in antimicrobial drug prescribing among office-based physicians in the United States.JAMA. 1995; 273: 214-219Crossref PubMed Scopus (742) Google Scholar The increased burden of antibiotics accounted for by RS in our study likely reflects these differences in methodology but may also reflect reduced antibiotic use for other diagnoses and reflexive increase in the proportion of antibiotics attributed to RS; such a determination is outside the scope of this study. Physicians prescribed antibiotics in the vast majority of ARS and CRS visits in this study. Major consensus guidelines recommend against antibiotic treatment for uncomplicated mild ARS,1Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.European position paper on rhinosinusitis and nasal polyps 2012.Rhinology. 2012; 50: 1-307Crossref PubMed Google Scholar, 2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar, 3Rosenfeld R.M. Andes D. Bhattacharyya N. Cheung D. Eisenberg S. Ganiats T.G. et al.Clinical practice guideline: adult sinusitis.Otolaryngol Head Neck Surg. 2007; 137: S1-S31Crossref PubMed Scopus (661) Google Scholar, 4Choosing wisely. Philadelphia: ABIM Foundation. Available from: http://www.choosingwisely.org/. Accessed August 5, 2013.Google Scholar, 5Chow A.W. Benninger M.S. Brook I. Brozek J.L. Goldstein E.J. Hicks L.A. et al.IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults.Clin Infect Dis. 2012; 54: e72-e112Crossref PubMed Scopus (447) Google Scholar and the role of antibiotics in CRS is controversial.2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar According to the 2005 Joint Task Force on Practice Parameters guidelines, antibiotics may be useful for acute exacerbation of chronic disease.2Slavin R.G. Spector S.L. Bernstein I.L. Kaliner M.A. Kennedy D.W. Virant F.S. et al.The diagnosis and management of sinusitis: a practice parameter update.J Allergy Clin Immunol. 2005; 116: S13-S47Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar However, there are no placebo-controlled trials regarding short-term antibiotic treatment of CRS without nasal polyps, but there is some evidence supporting long-term, low-dose macrolide antibiotics for 12 weeks for patients with CRS.1Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.European position paper on rhinosinusitis and nasal polyps 2012.Rhinology. 2012; 50: 1-307Crossref PubMed Google Scholar The 2012 European Position Paper on Rhinosinusitis and Nasal Polyps guidelines recommend initial long-term macrolide therapy for moderate/severe cases of CRS without nasal polyps. In our study, CRS was associated most frequently with penicillins/betalactams, followed by macrolides. Lee and Bhattacharyya8Lee L.N. Bhattacharyya N. Regional and specialty variations in the treatment of chronic rhinosinusitis.Laryngoscope. 2011; 121: 1092-1097Crossref PubMed Scopus (32) Google Scholar showed that amoxicillin and azithromycin were the most commonly prescribed antibiotics for CRS diagnoses in 2005-2006, with variations by region and physician specialty. They propose that a lack of evidence regarding CRS treatment may lead physicians to broadly prescribe medications without improving patient care or outcomes.8Lee L.N. Bhattacharyya N. Regional and specialty variations in the treatment of chronic rhinosinusitis.Laryngoscope. 2011; 121: 1092-1097Crossref PubMed Scopus (32) Google Scholar Ferguson et al suggest that objective evidence by endoscopy or computed tomography should be obtained if antibiotics are to be given for a prolonged duration, recommending a “moratorium for the widespread practice of a prolonged course of empiric antibiotics in patients with presumed CRS.”6Ferguson B.J. Narita M. Yu V.L. Wagener M.M. Gwaltney Jr., J.M. Prospective observational study of chronic rhinosinusitis: environmental triggers and antibiotic implications.Clin Infect Dis. 2012; 54: 62-68Crossref PubMed Scopus (37) Google Scholar Nevertheless, it is apparent that antibiotics are prescribed frequently for ARS and CRS. Our study relies on ICD-9 coding in a national database, and limitations include inability to reliably parse ARS from CRS and acute bronchitis from chronic bronchitis. Therefore, we present data based on individual ICD-9 codes, as well as combined codes for all forms of RS and forms of bronchitis (Fig 1). Inclusion of ARS along with CRS ICD-9 diagnoses ensures capture of all RS visits, including acute exacerbations of CRS that may be coded as ARS. Failure to adhere to recommended antibiotic treatment guidelines remains a significant issue in RS. Thus, current treatment recommendations should be promoted across specialties, and efforts to educate policymakers and the general public on the indications, benefits, and risks of antibiotics should be increased. This should be of high relevance to policymakers, patients, and clinicians. We thank Jane Holl, MD, director of the postdoctoral fellowship in Health Services Research, and Min-Woong Sohn, who provided statistical support, at the Northwestern University Institute for Healthcare Studies. None of the persons listed received compensation for their contributions.