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Review Article 


Abderrahman Mamoun Khalaf et al, 2019;3(8):643–647.

International Journal of Medicine in Developing Countries

Assessment of antibiotics’ use for the management of sinusitis in Saudi Arabia: a systematic review

Abderrahman Mamoun Khalaf1, Omair Al Hussain2, Saud Hatem Hamdi Aman3*, Doaa Hussain Alzaher4, Naif Ibrahim Sulaiman AlOudah3, Maab Abdulsalam Emam5, Sakinah Hassan Alzaher6, Abdullah Hatem Aman7

Correspondence to: Saud Hatem Hamdi Aman

*Medical College, Imam Mohammad Bin Saud University, Riyadh, Saudi Arabia.

Email: drsaudaman [at] yahoo.com

Full list of author information is available at the end of the article.

Received: 19 February 2019 | Accepted: 07 March 2019


ABSTRACT

Acute sinusitis is a common upper respiratory tract infection in children and adults that can be treated by conventional medication therapy to improve symptoms as supportive care. However, antibiotics are sometimes inappropriately prescribed, as sinusitis is commonly viral in origin. The rate of antibiotic abuse in sinusitis in both children and adults is considered high. This study evaluated the prescription of antibiotics in Saudi population for sinusitis either in acute or chronic setting. Educational and awareness programs are mandatory. Further studies are required to evaluate the knowledge and behavior of doctors on prescribing antibiotics for this indication.

Keywords:

Sinusitis, antibiotics, resistance, antibiotics abuse, Saudi Arabia.


Introduction

Acute sinusitis is a very frequent disease that is linked to functional and emotional, in addition to physical problems [1]. Furthermore, it can have increased costs for treatment, especially with antibiotics prescription. Sinusitis is described as a symptomatic inflammation that occurs in the sinuses, as well as nasal cavity [2].

Acute sinusitis is defined as symptoms persisting for less than 4 weeks. It is ideally a self-limiting illness; yet, there are possible rare aggressive manifestations that may occur with complicated sinusitis, like meningitis, brain abscesses, and orbital infection [3].

Because of rising worries due to increased antibiotic resistance and the frequent misdiagnosis of viral sinusitis with bacterial sinusitis, it is crucial to count for the indications of antibiotic management for acute sinusitis [4]. Recently, antibiotics are prescribed commonly for patients having acute sinusitis; even more, acute sinusitis is the fifth most prevalent medical condition to get an antibiotic prescription in the United States [5,6].

The treatment of acute sinusitis in adults has been very debatable for the past few decades because of questioning abuse of antibiotics, in addition to inappropriate use of radiographic strategies [7]. The problem of prescribing antibiotics, when not indicated for sinusitis, is even more complicated, especially in gulf area and Arab world where antibiotics could be dispensed in pharmacies without prescriptions [8,9]. This puts the whole community under a very high risk of spreading antimicrobial resistance and the absence of effective antibiotics when needed [10].

Therefore, the aim of this systematic review is to examine the literature for the use of antibiotics for the management of sinusitis in Saudi.


Materials and Methods

This systemic review was done on studies available in PubMed database in the period of 2009 and 2019, in order to evaluate the use of antibiotics in the management of sinusitis in Saudi population. Search terms included were a combination of antibiotics, sinusitis, and Saudi.

All the titles in addition to abstracts that appeared from this search were reviewed thoroughly. The results were then filtered to include original research articles investigating antibiotics’ use to treat sinusitis in adults and children in Saudi Arabia. The selected trials mentioned the examined antibiotics, in addition to the type of sinusitis either acute or chronic. Only trials published in English language were classified as related articles, which could be further evaluated in the second step.

The following step was determining the inclusion criteria to choose the studies that will be considered in the systemic review. Abstracts were revised manually to choose the appropriate abstracts to be considered. The inclusion criteria were the presence of sufficient details on the method of analysis and examined antibiotics and type of sinusitis. Moreover, only trials recruiting patients in Saudi Arabia were included.

Furthermore, references of selected trials were revised in order to define any related articles. Finally, the required data sets were collected from the final record of eligible articles and summarized.

Data were statistically described in terms of frequencies (number of cases) and valid percentages for categorical variables. Mean, standard deviations, minimum, and maximum were used to describe numerical variable. All statistical calculations were done using computer program IBM Statistical Package for the Social Science (SPSS; IBM Corp, Armonk, NY) release 21 for Microsoft Windows.


Results

A total of 79 articles were retrieved by searching PubMed. Following exclusion of articles on animals and including only trials on humans, 21 articles appeared. After searching the abstracts and checking for the eligibility criteria in identified potential abstracts, a total of six articles [1116] were considered as eligible to be included in the systematic review that were published between 2009 and 2019 covering a total of 9,529 adults and pediatric patients with sinusitis.

Out of the 9,529 sinusitis patients, only Shin et al. [12] included pediatrics, while Alanazi et al. [11] included both pediatrics and adults. The rest of studies [1316] included adult patients only. As for the type of sinusitis studied, Shin et al. [12] and El Banna et al. [15] included patients with chronic sinusitis, while the other four studies [11,13,14,16] included acute sinusitis.

Turning to study design, four studies had a prospective design [12,1416] where Shin et al. [12] did a case-control study while the others did observational studies. Alanazi et al. [11] had a retrospective design.

According to extracted results, all the trials considered the major objective as evaluating the use of antibiotic therapy in sinusitis in different ways. In addition, Shin et al. [12] evaluated the use of eosinophil-related markers and total IgE levels to evaluate antibiotic response in chronic sinusitis in children. The included trials are discussed in details in Table 1.


Discussion

Sinusitis is a common infection affecting patients from different age groups. It can be of either viral or bacterial origin. Most of the patients with acute sinusitis are prescribed antibiotics. However, this practice is not always the best treatment strategy.

The six trials [1116] agreed on the high incidence of antibiotic misuse, especially for amoxicillin and cephalosporin. This finding is considered alarming for decision-makers in order to start taking actions to increase awareness of medical staff and community as a whole on antibiotic use in sinusitis, particularly in vulnerable patient groups.

The most susceptible patient group to sinusitis is children, in the present systematic review, two trials included pediatric population. Shin et al. [12] did a case-control study that included 80 children with chronic sinusitis to evaluate the importance of eosinophil-related markers and IgE levels to assess antibiotic response. Shin et al. [12] showed that most of non-responders to antibiotics had an allergic disease with elevated inflammatory markers, including IgE levels. The antibiotic used in this study was amoxicillin/clavulanate or second or third cephalosporin.

In addition, acute sinusitis was also studied in Saudi children in Alanazi et al. [11]. This cross-sectional retrospective study evaluated the prescription of antibiotics in emergency department for acute sinusitis. The antibiotic prescribed was cephalosporin.

Alanazi et al. [11] revealed that the prevalence of medication errors in prescribing antibiotics was considered high, mainly because antibiotics were not indicated. However, only 39% of subjects included were pediatrics and 61% were adults.

Acute sinusitis in adults in Saudi Arabia was also studied by Shariff et al. [13]. This cross-sectional study identified risk factors of antibiotic resistance for treatment of acute sinusitis in Saudi Arabia. The study concluded that patient compliance and education regarding antibiotic therapy are the highest contributors to antibiotic resistance.

Turning to chronic sinusitis, El Banna et al. [15] studied the prevalence of bacterial chronic maxillary sinusitis in adults in Saudi Arabia, in addition to investigating the susceptibility of microorganisms to different antibiotic classes. El Banna et al. [15] found a strong correlation between chronic sinusitis and allergy. It was also concluded that vancomycin, cephalosporins, and clarithromycin showed high sensitivity.

It is worth mentioning that both Shin et al. [12] and El Banna et al. [15] showed a significant correlation between allergy and chronic sinusitis, in which El Banna et al. [15] investigated adult patients and Shin et al. [12] examined children.

It was obvious that all the studies focused on the increasing resistance of antibiotics. One of the major factors influencing this issue was dispensing antibiotics in pharmacies without prescription. This factor was examined by Abdulhak et al. [16].

In a prospective cross-sectional study on acute sinusitis, Abdulhak et al. [16] investigated the percent of pharmacies that dispensed antibiotics without prescription for acute sinusitis in Riyadh, in addition to investigating the potential risk of this practice. The study declared that 77.6% of the dispensed antibiotics for acute sinusitis were non-prescribed. Also, the study recommended that strict regulations should be made in order to limit this practice and protect the community from antimicrobial resistance.

Finally, to the author’s best knowledge, this is the first systemic review to give an updated insight from the literature during the last 10 years on the prescription of antibiotics in Saudi population for the management of acute sinusitis.

Table 1. A summary of the studies included in the review along with their results.

Author(s) Year Study design Sample size Age of patients Antibiotic examined Type of sinusitis Objective Result
Alanazi et al. [11] 2015 Cross sectional, Retrospective 5,752

61% adults

39% pediatrics

Cephalosporins Acute To evaluate antibiotic prescriptions in an emergency department of a tertiary care facility for acute sinusitis. Prevalence of antibiotic prescription errors in this emergency department was generally high and was particularly common with cephalosporin, fluoroquinolone antibiotics.
Shin et al. [12] 2015 Case-control 80 Children amoxicillin (90 mg/kg) plus clavulanic acid (6.4 mg/kg) and second or third generation of cephalosporin Chronic To evaluate the significance of eosinophil-related markers and total IgE levels in childhood chronic rhinosinusitis with regard to antibiotic response. There is a high prevalence of allergic diseases in the non-responder group;no response to antibiotics may be due to eosinophilic inflammation. Measurement of serum eosinophil cationic protein known as serum ECP may be useful in monitoring the progress of childhood chronic rhinosinusitis with regard to antibiotic response.
Shariff et al. [13] 2013 Cross-sectional 399 Adults Not Specified Acute To identify patient factors that contribute to development of antibiotic resistance in the treatment of acute sinusitis infection in the population of eastern province of Saudi Arabia Patient education on compliance to antibiotic therapy and education on implications of antibiotic resistance can be effective tools in controlling the lurking threat of antibiotic resistance in the population of Saudi Arabia.
Desrosiers et al. [14] 2013 Prospective, non-controlled, multi-center, observational, Phase IV cohort study 2,868 Adults moxifloxacin acute (1) to collect data on the characteristics of patients with acute bacterial sinusitis, the history and frequency of rhinosinusitis episodes, and the diagnostic procedures and therapeutic options chosen by investigators and (2) to evaluate the potential benefits of antibacterial therapy with moxifloxacin in patients with antibiotics to whom this treatment was prescribed in clinical practice. Thus, the study sought to improve the current understanding of this common disease and its routine clinical management. Moxifloxacin could be a valuable antibiotic choicefor the treatment of acute bacterial sinusitis.Targeted physician education on the evolution of clinical practice guidelines and the importance of the adherence to such guidelines, including the value of diagnostic tools and more judicious antibiotic selection for therapy would have an enormous impact on the overall outcome after antibiotic treatment for thisheterogeneous disease.
El-Banna et al. [15] 2013 Prospective 103 Adults Vancomycin, cefotaxime, cefaclor, clarithromycin, moxifloxacin, cefotaxime, and meropenem Chronic maxillary sinusitis Studying the prevailing bacterial etiology of chronic maxillary sinusitis in different age groups to evaluate the impact of predisposing factors to chronicity and toestimate the susceptibility of the isolated microorganisms to commonly used antimicrobial agents A strong association between chronic maxillarysinusitis and predisposing factors as allergic rhinitis, septal deviation,and nasal polyposis, but it showed a poor association with aspirin sensitivity. High susceptibility of all aerobic isolates to vancomycin, cefotaxime, cefaclor, and clarithromycin was detected, while anaerobic isolates showed high susceptibility to moxifloxacin, cefotaxime, and meropenem.
Abdulhak et al. [16] 2011 Cross-sectional prospective 327 Adults

Metronidazole

Ciprofloxacin

Amoxicillin/clavulanate

Acute To determine the percentage of pharmacies who sell antibiotics without medical prescriptions for acute sinusitis, examining the potential associated risks of such practice in Riyadh, Saudi Arabia. Antibiotics were dispensed without a medical prescription in 244 (77.6%) of 327, of which 231 (95%) were dispensed without a patient request.An antibiotic could be obtained in Riyadh without a medical prescription or anevidence-based indication with associated potential clinical risks. Strict enforcement and adherence to existing regulations are warranted

Conclusion

From this review, it is concluded that there is a high incidence of antibiotic abuse in adults and children for treatment of sinusitis, where antibiotics are usually prescribed even if sinusitis is not of bacterial origin. Further trials are necessary to evaluate the level of knowledge and attitude of healthcare professionals toward prescribing antibiotics in Saudi Arabia for acute sinusitis. Also, universities and hospitals should take the initiative to develop awareness and educational programs to the medical staff, as well as the public in order to highlight the hazards of this misuse of antibiotics.


List of Abbreviations

ECP eosinophil cationic protein
IgE Immunoglobulin E
SPSS Statistical Package for the Social Science

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Not applicable.


Ethical approval

Not applicable.


Author details

Abderrahman Mamoun Khalaf1, Omair Al Hussain2, Saud Hatem Hamdi Aman3, Doaa Hussain Alzaher4, Naif Ibrahim Sulaiman AlOudah3, Maab Abdulsalam Emam5, Sakinah Hassan Alzaher6, Abdullah Hatem Aman7

  1. Al-Amal Mental Health Complex, Riyadh, Saudi Arabia
  2. Assistant Professor of Otorhinolaryngology, ENT Consultant, Rhinologist, Anterior Skull Base Surgery, Head of Otorhinolaryngology Department, College of Medicine, Imam Mohammed Bin Saud University, Riyadh, Saudi Arabia
  3. Medical College, Imam Mohammad Bin Saud University, Riyadh, Saudi Arabia
  4. Medical University of Warsaw, Warsaw, Poland
  5. Almaarefa University, Riyadh, Saudi Arabia
  6. Mansoura University, Mansoura, Egypt
  7. Al Shamsi Hospital, Riyadh, Saudi Arabia

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How to Cite this Article
Pubmed Style

Khalaf AM, Hussain OA, Aman SHH, Alzaher DH, AlOudah NIS, Emam MA, Alzaher SH, Aman AH. Assessment of antibiotics' use for the management of sinusitis in Saudi Arabia: a systematic review. IJMDC. 2019; 3(8): 643-647. doi:10.24911/IJMDC.51-1550592238


Web Style

Khalaf AM, Hussain OA, Aman SHH, Alzaher DH, AlOudah NIS, Emam MA, Alzaher SH, Aman AH. Assessment of antibiotics' use for the management of sinusitis in Saudi Arabia: a systematic review. http://www.ijmdc.com/?mno=32426 [Access: September 23, 2019]. doi:10.24911/IJMDC.51-1550592238


AMA (American Medical Association) Style

Khalaf AM, Hussain OA, Aman SHH, Alzaher DH, AlOudah NIS, Emam MA, Alzaher SH, Aman AH. Assessment of antibiotics' use for the management of sinusitis in Saudi Arabia: a systematic review. IJMDC. 2019; 3(8): 643-647. doi:10.24911/IJMDC.51-1550592238



Vancouver/ICMJE Style

Khalaf AM, Hussain OA, Aman SHH, Alzaher DH, AlOudah NIS, Emam MA, Alzaher SH, Aman AH. Assessment of antibiotics' use for the management of sinusitis in Saudi Arabia: a systematic review. IJMDC. (2019), [cited September 23, 2019]; 3(8): 643-647. doi:10.24911/IJMDC.51-1550592238



Harvard Style

Khalaf, A. M., Hussain, . O. A., Aman, . S. H. H., Alzaher, . D. H., AlOudah, . N. I. S., Emam, . M. A., Alzaher, . S. H. & Aman, . A. H. (2019) Assessment of antibiotics' use for the management of sinusitis in Saudi Arabia: a systematic review. IJMDC, 3 (8), 643-647. doi:10.24911/IJMDC.51-1550592238



Turabian Style

Khalaf, Abderrahman Mamoun, Omair Al Hussain, Saud Hatem Hamdi Aman, Doaa Hussain Alzaher, Naif Ibrahim Sulaiman AlOudah, Maab Abdulsalam Emam, Sakinah Hassan Alzaher, and Abdullah Hatem Aman. 2019. Assessment of antibiotics' use for the management of sinusitis in Saudi Arabia: a systematic review. International Journal of Medicine in Developing Countries, 3 (8), 643-647. doi:10.24911/IJMDC.51-1550592238



Chicago Style

Khalaf, Abderrahman Mamoun, Omair Al Hussain, Saud Hatem Hamdi Aman, Doaa Hussain Alzaher, Naif Ibrahim Sulaiman AlOudah, Maab Abdulsalam Emam, Sakinah Hassan Alzaher, and Abdullah Hatem Aman. "Assessment of antibiotics' use for the management of sinusitis in Saudi Arabia: a systematic review." International Journal of Medicine in Developing Countries 3 (2019), 643-647. doi:10.24911/IJMDC.51-1550592238



MLA (The Modern Language Association) Style

Khalaf, Abderrahman Mamoun, Omair Al Hussain, Saud Hatem Hamdi Aman, Doaa Hussain Alzaher, Naif Ibrahim Sulaiman AlOudah, Maab Abdulsalam Emam, Sakinah Hassan Alzaher, and Abdullah Hatem Aman. "Assessment of antibiotics' use for the management of sinusitis in Saudi Arabia: a systematic review." International Journal of Medicine in Developing Countries 3.8 (2019), 643-647. Print. doi:10.24911/IJMDC.51-1550592238



APA (American Psychological Association) Style

Khalaf, A. M., Hussain, . O. A., Aman, . S. H. H., Alzaher, . D. H., AlOudah, . N. I. S., Emam, . M. A., Alzaher, . S. H. & Aman, . A. H. (2019) Assessment of antibiotics' use for the management of sinusitis in Saudi Arabia: a systematic review. International Journal of Medicine in Developing Countries, 3 (8), 643-647. doi:10.24911/IJMDC.51-1550592238