Top POEMs of 2018 Consistent with the Principles of the Choosing Wisely Campaign: Infections

Top 20 POEMs of 2018 Consistent with the Principles of the Choosing Wisely Campaign

Broad-Spectrum ABX Increase Adverse Events in Children with Acute Respiratory Infections with Minimal Benefit

Clinical question
Are broad-spectrum antibiotics the preferred treatment in children with acute respiratory tract infections?

Bottom line
Broad-spectrum antibiotics are no more effective than narrow-spectrum antibiotics for treating acute respiratory tract infections in infants and children, and adverse events are significantly more common in children treated with broad-spectrum antibiotics. (LOE = 2b-)(

Gerber JS, Ross RK, Bryan M, et al. Association of broad- vs narrow-spectrum antibiotics with treatment failure, adverse events, and quality of life in children with acute respiratory tract infections. JAMA 2017;318(23):2325-2336.

Study design: Cohort (retrospective)

Funding source: Government

Setting: Population-based

These investigators collected data both retrospectively and prospectively from a network of pediatric primary care practices on outcomes of infants and children, aged 6 months to 12 years, who met international standards for the diagnosis of acute respiratory tract infection, including otitis media, group A streptococcal pharyngitis, and sinusitis. Exclusion criteria included not receiving a prescription for an oral antibiotic, antibiotic use in the last 30 days, and being younger than 3 years with a diagnosis of group A streptococcal pharyngitis. The children who were prescribed broad-spectrum antibiotics, including amoxicillin-clavulanate, cephalosporins, and macrolides, were defined as exposed; children who were prescribed narrow-spectrum antibiotics, including penicillin and amoxicillin, were defined as unexposed. The authors do not specifically state whether the individuals who assessed outcomes remained masked to group assignments. Of the 30,159 children in the retrospective cohort that met inclusion criteria with complete data, 4307 (14%) were prescribed broad-spectrum antibiotics. Broad-spectrum antibiotic use was not significantly associated with a lower rate of treatment failure compared with narrow-spectrum antibiotics (3.4% vs 3.1%, respectively). Similarly broad-spectrum antibiotics were not associated with a clinically significant difference in quality of life scores compared with narrow-spectrum antibiotics. However, broad-spectrum antibiotics were significantly associated with a higher risk of reported adverse events compared with narrow-spectrum antibiotics (3.7% vs 2.7%, respectively, as documented by clinicians, and 35.6% vs 25.1%, respectively, as documented by the parents and/or patients). Adverse events included diarrhea, candidiasis, rash, other unspecified allergic reactions, and vomiting.

David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC

Chronic Sinusitis: Saline Irrigation Helps Somewhat; Steroid Doesn't Add More Benefit

Clinical question
In patients with chronic rhinosinusitis, does the addition of budesonide to a saline irrigation solution result in further improvement in symptoms?

Bottom line
This study showed that patients with chronic rhinosinusitis who continue to use a saline nasal wash (NeilMed) will often experience an improvement in symptoms that can be clinically meaningful, but the addition of the corticosteroid budesonide has yet to be shown to provide extra benefit. (LOE = 2b)(

Tait S, Kallogjeri D, Suko J, Kukuljan S, Schneider J, Piccirillo JF. Effect of budesonide added to large-volume, low-pressure saline sinus irrigation for chronic rhinosinusitis. A randomized clinical trial. JAMA Otolaryngol Head Neck Surg 2018;144(7):605-612.

Study design: Randomized controlled trial (double-blinded)

Funding source: Self-funded or unfunded

Allocation: Uncertain

Setting: Outpatient (specialty)

These researchers recruited 80 patients with chronic rhinosinusitis (2 or more symptoms, including mucopurulent drainage, nasal obstruction, facial pain, and decreased sense of smell at least 12 weeks) to be randomized, allocation concealment unknown, to receive treatment using a large-volume saline sinus irrigation with either placebo or budesonide 1 mg once daily for 30 days. The patients, average age 51 years, had a Sino-Nasal Outcome Test (SNOT-22) score of 44.1 out of a possible 110. A significant number of patients dropped out (23%), leaving 61 to be evaluated. The average decrease in scores was 20.7 points in the treated group and 13.6 points in the control group, which was not statistically significant. More participants in the treated group (79%) received a clinically important benefit of at least a 9-point improvement than in the saline-only group (59%; not statistically different). This small study, with significant dropouts, did not have the power to find a difference if one exists. I'm a little grumpy that the authors did not give specific data to judge the degree of benefit beyond a 9-point improvement for the responders.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

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