Di­ag­nos­tic tool for si­nuses could help pa­tients and fight an­tibi­otic re­sis­tance

The Catoosa County News - - COMMENTARY - By Erica Hens­ley

Di­ag­nos­tic tool for si­nuses could help pa­tients . . . and fight an­tibi­otic re­sis­tance

Most Ge­or­gians know the ir­ri­tat­ing sen­sa­tion of not be­ing able to breathe through their noses dur­ing cold or pollen sea­son. It may be caused by chronic si­nusi­tis or si­nus in­fec­tion, and most cases of both types clear up on their own.

Si­nus in­fec­tions oc­cur when cav­i­ties around the nose are in­flamed, mak­ing breath­ing dif­fi­cult. Though bac­te­ria cause a small num­ber of si­nus in­fec­tions, most are vi­ral and should not be treated with an­tibi­otics, ac­cord­ing to the CDC.

Stud­ies show that about three-quar­ters of pa­tients who see doc­tors for si­nus com­plaints leave with pre­scrip­tions for an­tibi­otics. Un­for­tu­nately, these of­ten don’t meet the pre­scrib­ing guide­lines that are meant to curb un­nec­es­sary use of the germ-fight­ing drugs.

This wor­ries Dr. Mark Ebell, a Ge­or­gia physi­cian, who is re­search­ing how si­nus in­fec­tion mis­di­ag­no­sis — and sub­se­quently an­tibi­otic re­sis­tance — can be re­duced.

Res­pi­ra­tory in­fec­tions are the most com­mon rea­son for an­tibi­otic use in the United States, and of those, si­nus in­fec­tions are re­spon­si­ble for more un­nec­es­sary an­tibi­otics than any other, ac­cord­ing to Ebell, an epi­demi­ol­ogy pro­fes­sor at the Univer­sity of Ge­or­gia.

Ebell has de­vel­oped a di­ag­nos­tic tool to help physi­cians dis­tin­guish be­tween vi­ral and bac­te­rial in­fec­tions.

“Pa­tients need to re­al­ize that most of these [si­nus in­fec­tions] are vi­ral, and that an­tibi­otics are only rec­om­mended if symp­toms are se­vere or have lasted more than 10 days,” he says.

Signs that might in­di­cate a bac­te­rial si­nus in­fec­tion in­clude pain on one side of the face, in the cheek and in the up­per teeth, Ebell says. Some­one who has a cold and be­gins to get bet­ter, but then starts feel­ing much worse, is an­other type of pa­tient who may have a bac­te­rial in­fec­tion, he says.

Ebell has de­vel­oped a clin­i­cal de­ci­sion rule for di­ag­nos­ing si­nus in­fec­tions. It in­cor­po­rates pa­tient symp­toms and a sim­ple blood test to more ac­cu­rately de­tect bac­te­rial in­fec­tions.

The tool is the first of its kind, and he says it can help physi­cians and pa­tients know when to reach for an­tibi­otics, and most im­por­tantly, when not to do so.

An­tibi­otic re­sis­tance is a grow­ing pub­lic health threat, and though it oc­curs nat­u­rally, it is be­ing sped up by mis­use of med­i­ca­tion.

More than 2 mil­lion ill­nesses and 23,000 deaths have been caused by an­tibi­otic re­sis­tance, ac­cord­ing to CDC. Re­sis­tant bac­te­ria make it harder to treat in­fec­tions such as pneu­mo­nia, tu­ber­cu­lo­sis and gon­or­rhea.

The specter of an­tibi­otic re­sis­tance

The World Health Or­ga­ni­za­tion warns that with­out ur­gent re­duc­tion of an­tibi­otic mis­use and overuse, we will en­ter a “postan­tibi­otic era” in which com­mon in­fec­tions and mi­nor in­juries can kill.

Ebell and Dan­ish re­searcher Dr. Jens Hansen recorded symp­toms and re­sults from a blood test that re­ports C-re­ac­tive pro­tein lev­els (CRP test) for 175 pa­tients who showed signs of si­nus in­fec­tion, to de­ter­mine pa­tients’ like­li­hood of bac­te­rial in­fec­tion based on body in­flam­ma­tion.

The re­sult­ing “si­nus score” gives physi­cians an easy-to-use thresh­old in­di­cat­ing if the pa­tient is at low, mod­er­ate or high risk for bac­te­rial in­fec­tion. If all high-risk and half of mod­er­ate-risk pa­tients were treated with an­tibi­otics, about one-third of all si­nus pa­tients in the study would re­ceive an­tibi­otics, a dra­matic con­trast to cur­rent pre­scrip­tion prac­tices of 75 per­cent.

Some bac­te­rial in­fec­tions re­quire an­tibi­otics. But be­cause so many an­tibi­otics have been pumped into our bod­ies and food since they gained main­stream use in the 20th cen­tury, bac­te­ria have grown more and more re­sis­tant to drugs that once proved ef­fec­tive at killing the bugs.

“Pri­mary care physi­cians are well aware that it’s a prob­lem, and are con­cerned about it,” says Ebell. “How­ever, pa­tients have come to ex­pect an an­tibi­otic for all si­nus in­fec­tions, as well as many other res­pi­ra­tory in­fec­tions, and doc­tors place value on hav­ing a sat­is­fied pa­tient.”

“But, while we have tools like the strep test to avoid an­tibi­otics in pa­tients with vi­ral pharyn­gi­tis, and the in­fluenza point-of­care test for pa­tients with flu-like ill­ness to avoid un­nec­es­sary use of [an­tibi­otics], we have no such tools for pa­tients with si­nusi­tis or acute bron­chi­tis,” he said.

Be­cause si­nus symp­toms are a ma­jor pa­tient con­cern, there is of­ten stress and mis­in­for­ma­tion sur­round­ing the di­ag­no­sis, says Dr. Ed­die Richard­son Jr., pres­i­dent of the Ge­or­gia Acad­emy of Fam­ily Physi­cians.

“Pa­tients want re­lief, and this is a cus­tomer ser­vice busi­ness,” says Richard­son, who runs Lake Oconee Ur­gent and Spe­cialty Care Cen­ter, when asked about Ebell’s re­search.

Richard­son says res­pi­ra­tory is­sues in­crease to about 20 per­cent of his busi­ness dur­ing Oc­to­ber. He says it can be dif­fi­cult to ex­plain to pa­tients why their par­tic­u­lar symp­toms don’t war­rant the use of an­tibi­otics. “I try to get them symp­to­matic re­lief, like nasal sprays, be­fore [pos­si­bly] putting them on an­tibi­otics, and talk to them about how their en­vi­ron­ment might cause [al­lergy] ex­po­sure.”

Richard­son says the time frame of a pa­tient’s symp­toms and the per­son’s his­tory of al­ler­gies, plus what shows up in a phys­i­cal exam, are im­por­tant fac­tors in whether he de­cides to pre­scribe an­tibi­otics. A test that helps give ob­jec­tive data about si­nus in­fec­tion thresh­olds could help his pa­tients un­der­stand why he makes his de­ci­sion, he says.

More re­search is needed to test the si­nus score in a clin­i­cal set­ting, but the CRP di­ag­nos­tic tool is used in some Euro­pean coun­tries and in some U.S. labs.

There are still some prac­ti­cal ob­sta­cles to wide­spread use of the test. Most pri­mary care set­tings do not have the “mod­er­ate com­plex­ity lab cer­ti­fi­ca­tion” to use the CRP test based on FDA reg­u­la­tions, and Ebell hopes stud­ies like his will en­cour­age the FDA to loosen these re­stric­tions.

Ebell says the tool is a win-win for doc­tors, pa­tients and so­ci­ety at large to help re­duce an­tibi­otic re­sis­tance.

“Doc­tors are gen­er­ally ask­ing these ques­tions al­ready, and the clin­i­cal de­ci­sion rule helps them in­ter­pret the an­swers in a more mean­ing­ful, clin­i­cally use­ful way by com­bin­ing the most in­for­ma­tive signs and symp­toms,” Ebell says. “While the CRP blood test would take about 5 min­utes, if ap­proved by the FDA, then [doc­tors] could bill for it and even make a small profit.”

The study, “Pro­posed Clin­i­cal De­ci­sion Rules to Di­ag­nose Acute Rhi­nos­i­nusi­tis Among Adults in Pri­mary Care,” pub­lished in An­nals of Fam­ily Medicine, is avail­able on­line at http:// www.an­n­fammed.org/ con­tent/15/4/347.

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