Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate

Measure Specification

The rationale for antibiotic therapy of ABRS is to eradicate bacterial infection from the sinuses, hasten resolution of symptoms, and enhance disease-specific quality of life. Antibiotic therapy should be efficacious, cost-effective, and result in minimal side effects. The justification for amoxicillin as first-line therapy for most patients with ABRS relates to its safety, efficacy, low cost, and narrow microbiologic spectrum.

Consideration to prescribing amoxicillin-clavulanate for adults with ABRS is given to those at a high risk of being infected by an organism resistant to amoxicillin. Factors that would prompt clinicians to consider prescribing amoxicillin-clavulanate instead of amoxicillin include: • Situations in which bacterial resistance is likely (e.g., antibiotic use in the past month; close contact with treated individuals, health care providers, or a health care environment; failure of prior antibiotic therapy; breakthrough infection despite prophylaxis; close contact with a child in a daycare facility; smoker or smoker in the family; high prevalence of resistant bacteria in community) • Presence of moderate to severe infection (e.

g., moderate to severe symptoms of ABRS; protracted symptoms of ABRS; frontal or sphenoidal sinusitis, history of recurrent ABRS) • Presence of comorbidity or extremes of life (e.g., comorbid conditions including diabetes; chronic cardiac, hepatic, or renal disease; immunocompromised patient; age greater than 65 years) The use of high-dose amoxicillin with clavulanate is recommended for adults with ABRS who are at a high risk of being infected with an amoxicillin-resistant organism.

High-dose amoxicillin is preferred over standard-dose amoxicillin primarily to cover penicillin non susceptible (PNS) S. pneumoniae. This risk exists in those from geographic regions with high endemic rates (>10%) of invasive PNS S. pneumoniae, those with severe infection (e.g., evidence of systemic toxicity with fever of 39C (102F) or higher, and threat of suppurative complications), age >65 years, recent hospitalization, antibiotic use within the past month, or those who are immunocompromised.

The following evidence statements are extracted from the referenced clinical guidelines: AAO-HNS Sinusitis Guideline (2015) If a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin with or without clavulanate as first-line therapy for most adults. Recommendation based on randomized controlled trials with heterogeneity and non-inferiority design with a preponderance of benefit over harm.

The purpose of this statement is to promote prescribing of antibiotics with known efficacy and safety for ABRS and to reduce prescribing of antibiotics with potentially inferior efficacy because of more limited coverage of the usual pathogens that cause ABRS in adults. A secondary goal is to promote cost-effective antibiotic therapy for ABRS. A quality improvement opportunity addressed by this guideline key action statement is discouraging initial prescribing of antibiotics other than amoxicillin, with or without clavulanate, that may have low efficacy or have comparable efficacy but more adverse events.

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults (2012) Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in adults (weak, low). Evidence for at least 1 critical outcome from observational studies, from RCTs with serious flaws or indirect evidence.

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once.