Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)

Measure Specification

Antibiotic treatment for sinusitis is indicated for some patients, but overtreatment of acute sinusitis with antibiotics is common and often not indicated. Further, treatment with antibiotics may increase patient harm and can lead to antibiotic resistance. A 2018 Cochrane systematic review update was undertaken to assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings.

1 Acute rhinosinusitis is a common condition that involves blockage of the nose passage and mucus in the sinuses. It is often caused by a viral upper respiratory tract infection of which only 0.5% to 2% of cases are estimated to be complicated by a bacterial rhinosinusitis. Nevertheless, antibiotics (used to treat bacterial infections) are often prescribed.

Unnecessary prescribing contributes to antimicrobial resistance in the community. The authors concluded that given the lack of clear benefit in terms of rapid recovery and the increase in side effects in participants treated with antibiotics, antibiotics are not recommended as first line treatment in adults with clinically diagnosed acute rhinosinusitis.

The following evidence statements are extracted from the referenced clinical guidelines: AAO-HNS Sinusitis Guideline (2015). Clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and non-infectious conditions. A clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis (purulent nasal drainage accompanies by nasal obstruction, facial pain-pressure- fullness, or both) persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening).

Strong recommendation based on diagnostic studies with minor limitations and a preponderance of benefit over harm. The purpose of this statement is to emphasize the importance of differentiating acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis (ARS) caused by viral upper respiratory infections to prevent unnecessary treatment with antibiotics.

Distinguishing presumed bacterial vs. viral infection is important because antibiotic therapy is inappropriate for the latter. A quality improvement opportunity addressed by this guideline key action statement is the avoidance of inappropriate use of antibiotics for presumed viral infections. More than one in five antibiotics prescribed in adults are for sinusitis, making it the fifth most common diagnosis responsible for antibiotic therapy.

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation of this measure, each unique occurrence starts with the onset of AVS symptoms and concludes with the resolution of AVS symptoms or after 90 days if a resolution of AVS symptoms is not documented.

A new occurrence of AVS cannot start until the previous occurrence during the performance period has concluded. If multiple denominator eligible encounters are documented within an identified occurrence, MIPS eligible clinicians should submit the most recent encounter associated within that occurrence. This is an inverse measure which means a lower calculated performance rate for this measure indicates better clinical care or control.

The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.