IMPACT OF FIRST-LINE VERSUS SECOND-LINE ANTIBIOTICS FOR THE TREATMENT OF ACUTE UNCOMPLICATED SINUSITIS
[Piccirillo JF et al. JAMA 2001;286:1849]:
The authors performed a retrospective study using data from Express Scripts Patient Treatment Episode Registry with over 2.1 million subscribers. The analysis was done using the ICD-9 code for acute sinusitis and correlated with antibiotic treatment and outcome. Antibiotics were classified as “first-line” (amoxicillin, TMP-SMX, or erythromycin) or “second-line” (clarithromycin, azithromycin, amoxicillin-clavulanate, cephalosporin, or fluoroquinolone). The total number of patients studied was 29,102. Of these, 60% received first-line agents and 40% received second-line agents. The results showed an overall success rate of 90%, failure rate of 3%, and relapse rate of 6%. There was no difference in outcome based on classification of antibiotic as first-line or second-line. With regard to physicians, most received care from a “primary care physician,” but a small number saw a specialist; the specialists were far more likely to prescribe second-line agents. Details are shown in Table 7.
The data from this study do not address the issue of antibiotic indications for acute sinusitis, but do deal with the selection of antibiotics once that decision has been made. A review by the Cochrane Library showed that no antibiotic was superior to amoxicillin according to prior therapeutic trials, although some are concerned that most of the trials considered adequate in design were done prior to the emergence of penicillin-resistant S. pneumoniae. Nevertheless, amoxicillin is the preferred drug according to guidelines of the American College of Physicians, the IDSA, the CDC, and the American Association of Otolaryngologists. Of interest in this review is that amoxicillin accounted for 40% of all prescriptions, TMP-SMX was second with 15%, and multiple cephalosporins added up to 13%, and clarithromycin plus azithromycin accounted for 19%. A major difference between the two groups was the cost of care, which was substantially higher in those receiving “second-line drugs,” and this difference was due primarily to the cost of antibiotic prescriptions, which was an average of $81 for second-line agents versus $18 for first-line agents.