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Physicians Urged To Avoid Prescribing More Costly, Second-Line Antibiotics as Initial Drug Therapy
October 16, 2001 — Patients who receive newer, more expensive antibiotics for acute uncomplicated sinusitis have about the same rate of successful treatment as those treated with older, less expensive antibiotics, but the cost of care is significantly higher with the newer drugs, according to an article in the October 17 issue of The Journal of the American Medical Association.
Jay F. Piccirillo, M.D., of Washington University School of Medicine, St. Louis, and colleagues compared the effectiveness and health care charges of antibiotics in two categories, first-line or second- line, based on accepted treatment guidelines for the treatment of acute uncomplicated sinusitis in adults. First-line antibiotics (older and less expensive drugs) include amoxicillin (a type of penicillin), trimethoprin-sulfamethoxazole and erythromycin. Second-line antibiotics (generally newer and more expensive drugs) include clarithromycin, azithromycin, amoxicillin/clavulanate, cefuroxine, ciprofloxacin and others.
Sinusitis, an inflammation or infection involving the linings of the sinuses, can be allergic, bacterial or viral in nature. The condition may include nasal congestion, sneezing, coughing, fever, headache, facial pain and other symptoms, depending on the cause and type. Acute sinusitis involves less than two weeks of symptoms.
According to background information cited in the article, about 35 million people in the United States have some form of sinusitis, and in 1996 the direct cost of this disorder in the United States was more than $3.3 billion. Acute sinusitis may lead to a number of different complications — including bacterial meningitis or periorbital cellulitis (an infection of the tissues surrounding the eye). Studies suggest little additional benefit in the relief of acute sinusitis symptoms from the use of newer, more expensive, second-line antibiotics instead of older, less expensive, first-line antibiotics. However, researchers have failed to include the development of complications and the cost of care in their analyses.
The authors analyzed data from a pharmaceutical database containing demographic, clinical, treatment and charge information for 29,102 adults with a diagnosis of acute sinusitis. The patients received initial antibiotic treatment between July 1, 1996 and June 30, 1997. There were 17 different drugs prescribed — three first-line antibiotics and 14 second-line antibiotics.
"The success rate for the 17,329 patients who received a first-line antibiotic was 90.1 percent and for the 11,773 patients who received a second-line antibiotic was 90.8 percent, a difference of 0.7 percent," they report.
Two patients developed a complication of acute sinusitis in the 28-day follow-up period. "In both cases, the complication was periorbital cellulitis. One patient had received a first-line antibiotic while the other received second-line therapy," the authors write.
There were significant differences in the average charges for care for patients treated with first-line and second-line antibiotics. "The average total direct charge for patients receiving a first-line antibiotic was $68.98 and a second-line antibiotic was $135.17, a difference of $66.19," the authors report. "This difference was due entirely to the difference in charge of antibiotics and not other charges, such as professional fees, laboratory tests or emergency department visits."
"Due to the higher expense and potential for the development of resistant bacteria, physicians should avoid prescribing second-line antibiotics as the initial antibiotic treatment," the authors suggest. "Health departments, physician specialty organizations, managed care organizations, pharmacy benefits managers and industry should promote recommendations for the use of narrow-spectrum, less expensive antibiotics (e.g., amoxicillin, trimethoprim/sulfamethoxazole or erythromycin) rather than broader-spectrum, more expensive antibiotics.
Editor's Note: Dr. Piccirillo had served as a consultant to Express Scripts Inc. in St. Louis, an independent pharmacy benefits manager. This research was supported by Express Scripts Inc. Express Scripts Inc. research programs are not obligated to any health care provider or pharmaceutical company.