Background. Background. AAP (2013) Guidelines. Background 4/19/2016

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1 Disclosure Information for: Amanda Kotowski and Laurie Newton Diagnosis & Management of Pediatric Sinusitis: A Survey of Primary Care, Otolaryngology & Urgent Care Providers Amanda Kotowski, DNP, CPNP Laurie Newton, DNP, CPNP Melissa Grinker, MSN, RN Robert Chun, MD Diagnosis and Management of Pediatric Sinusitis: A Survey of Primary Care, Otolaryngology and Urgent Care Providers Learners must fill out and turn in evaluations to successfully complete this program. WNA CEAP or ANCC does not endorse any products within this There are no relevant financial relationships related to this There is no sponsorship/commercial support of this There is no off-label drug use described in this The content being presented will be fair, well-balanced and evidence-based. Estimated prevalence of 20 million cases of acute rhinosinusitis (ARS) occurring annually in the United States Between 6-7% of children seeking care for respiratory symptoms has an illness consistent with acute bacterial sinusitis Fifth most common condition for which an antibiotic is prescribed in the US o Guidelines recommend to restrict the use of antibiotics o Estimated that <2% of ARS cases are bacterial Antibiotics are the most common prescription drugs given to children o 75% of antibiotic prescriptions are given for acute respiratory tract infections (Smith et al., 2013; Wald et al., 2013) (Gerber et al., 2013; Hersh et al., 2011; McNeeley, 2012; Pynnonen et al., 2015; Venekamp et al., 2012) Studies suggest that guidelines for the diagnosis and management of ARS have not been effectively translated into routine practice o American Academy of Pediatrics 2013 o Infectious Disease Society of America 2012 AAP (2013) Guidelines Diagnosis o Persistent illness, ie, nasal discharge (of any quality) or daytime cough or both lasting more than 10 days without improvement OR o Worsening cough, ie, worsening or new onset of nasal discharge, daytime cough or fever after initial improvement OR o Severe onset, ie, concurrent fever (temperature o F) and purulent nasal discharge for at least 3 consecutive days (Chow et al., 2012; Sharp et al., 2015; Wald et al., 2013) (Wald et al., 2013) 1

2 AAP (2013) Guidelines Purpose Treatment o Amoxicillin with or without clavulanate as first-line treatment 80 to 90 mg/kg per day with risk factors o Antibiotic treatment for 7 days after symptom resolution o 72 hours as the time to assess treatment failure o No recommendations on: Intranasal steroids Saline irrigation Nasal decongestants, mucolytics and antihistamines (Wald et al., 2013) 1. To assess pediatric PCP, pediatric otolaryngology (ENT) and pediatric urgent care () providers perception of their adherence to the 2013 AAP guidelines for the diagnosis and management of ARS in children 1 to 18 years old. 2. To compare and contrast the diagnosis and management of ARS across the specialties of pediatric primary care, pediatric ENT and pediatric. Framework Quality Improvement Project o Utilizes established benchmarks and indicators to evaluate and improve practice Avedis Donabedian s Structure-Process-Outcomes Model No IRB approval required Structure Process Outcomes Provider Survey A 21-item questionnaire (CVI.9) was designed by the investigators using Survey Monkey Survey was ed to a total of 138 providers in Southeastern Wisconsin (94 PCP, 25 and 19 ENT) from: o 20 pediatric primary care clinics o 1 pediatric urgent care () practice o 1 pediatric otolaryngology (ENT) specialty practice 50.1% response rate (70 providers) o Anonymous survey (Donabedian, 2005; Raines, 2012) Sample of Survey Questions Diagnosis o Diagnostic criteria utilized o Utilization of nasal culture o Utilization of CT scan Management o Typically utilized antibiotics o First line antibiotic treatment choice for children with penicillin allergy; for child in daycare o Length of antibiotic therapy o Approach to treatment failure o Adjuvant therapies routinely used % Persistent symptoms >10 days Sinusitis Diagnosis 7 Worsening of viral URI symptoms at days % Severe onset & purulent nasal discharge for 3 days 6% Halitosis with nasal congestion of any length of time 2

3 o ENT (78.6%), PCP (19.4%) and (5%) will culture their patients o ENT providers (57%) are comfortable with a nasal culture being obtained by PCPs o PCP (41.5%) and (3) think a patient should be seen by ENT for a nasal culture Persistant symptoms on antibiotic before changing agents Pt tx with several antibiotics and still symptomatic Nasal Culture Indication Pt with s/sx of chronic sinusitis PCP ENT Sinusitis Management: Antibiotic Choice ENT PCP For PCN allergic patients, most providers use cefdinir (88%) and azithromycin (7%) Typical length of antibiotic therapy prescribed by all providers is 10 days (7) and 14 days (14%) ENT (21%) prescribes 7 days past any symptom compared to PCP (8%) and (5%) Sinusitis Management: Adjuvant Therapies ENT PCP Do not routinely order sinus CT Order a sinus xray before a sinus CT Sinusitis Management: Imaging 4 Prior to ENT referral To confirm sinusitis diagnosis PCP Worried about complication of sinusitis

4 Conclusions o Providers diagnostic criteria for ARS is consistent amongst the 3 specialties and in accordance with the 2013 AAP guidelines. o Variation exists in clinical management between the 3 specialties o Variation in length of antibiotic treatment o Variation in adjuvant therapy use o Imaging is not routinely ordered by PCP/. Conclusions The majority of ENT providers obtain nasal cultures for patients with chronic or recurrent acute sinusitis ENT providers perceive that it is appropriate for PCPs to obtain nasal cultures; however, the majority of PCPs do not obtain cultures The perceived indication for obtaining a nasal culture varies between the 3 specialties Recommendations Dissemination of results to all participants Educate all providers on the current 2013 AAP guidelines o Include RNs who may help with patient education Define practice across all settings Small sample size Respondents were from one pediatric system Response bias Limitations Acknowledgments Alex Romashko, MD Questions Amy Romashko, MD Smriti Khare, MD Cecille Sulman, MD 4

5 References References Chow, A., W., Benninger, M. S., Brook, I., Brozek, J. L., Goldstein, E. J., Hicks, L. A., File, T. M. (2012). IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases, e1-e41. Donabedian, A. (2005). Evaluating the quality of medical care. The Milbank Quarterly, 83 (4), Gerber, J. S., Prasad, P. A., Fiks, A. G., Localio, A. R., Grundmeier, R. W., Bell, L. M., Zaoutis, T. E. (2013). Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA, 309, Hersh, A. L., Shapiro, D. J., Pavia, A. T., & Shah, S. S. (2011). Antibiotic prescribing in ambulatory pediatrics in the united states. Pediatrics, 128, McNeeley, S. M. (2012). Rhinosinusitis: An urgent care perspective. American Journal of Clinical Medicine, 9(2), McQuillan, L., Crane, L. A., & Kempe, A. (2009). Diagnosis and management of acute sinusitis by pediatricians. Pediatrics, 123(2), Pynnonen, M. A., Lynn, S., Kern, H. E., Novis, S. J., Akkina, S. R., Keshavarzi, N. R., & Davis, M. M. (2015). Diagnosis and treatment of acute sinusitis in the primary care setting: A retrospective cohort. The Laryngoscope, 00, 1-7. Raines, D. A. (2012). Quality improvement, evidence-based practice and nursing research Oh my! Neonatal Network, 31(4), Sarpong, E. M., & Miller, G. E. (2014). Narrow-and broad-spectrum antibiotic use among US children. Health Services Research, 50(3), Sharp, A. L., Klau, M. H., Keschner, D. Macy, E., Tang, T., Shen, E., Gould, M. K. (2015). Low-value care for acute sinusitis encounters: Who s choosing wisely? American Journal of Managed Care, 21(7), Smith, S. S., Kern, R. C., Chandra, R. K., Tan, B. K., & Evans, C. T. (2013). Variations in antibiotic prescribing of acute rhinosinusitis in united states ambulatory settings. Otolaryngology Head and Neck Surgery, 148(5), Wald, E. R.., Applegate, K. E., Bordley, C., Darrow, D. H., Glode, M. P., Marcy, M., Weinberg, S. T. (2013). Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics, 132, e262-e280. Venekamp, R. P., Rovers, M. M., Verheij, T. J., Bonten, M. J., & Sachs, A. P. (2012). Treatment of acute rhinosinusitis: Discrepancy between guideline recommendations and clinical practice. Family Practice, 29,