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New Guide Defines Best Practices for Adult Acute Bacterial Rhinosinusitis

Efforts seeks to reduce overprescription of antibiotics and ineffective care for acute sinusitis

UH Innovations in Otolaryngology - Head & Neck Surgery - Fall 2018



Otolaryngology—Rhinology and Skull Base Surgery, UH Cleveland Medical Center; Assistant Professor, Otolaryngology, Case Western Reserve University School of Medicine

Kenneth Rodriquez, MD


Chief, Rhinology and Skull Base Surgery, UH Cleveland Medical Center; Assistant Professor, Otolaryngology, Case Western Reserve University School of Medicine

Otolaryngologists at University Hospitals Cleveland Medical Center have established a system-wide Clinical Practice Guideline (CPG) for the diagnosis and treatment of adult acute bacterial rhinosinusitis (ABRS).

“As a department, we looked at quality measures that could be improved across our health system,” says Brian D’Anza, MD, Otolaryngology—Rhinology and Skull Base Surgery, UH Cleveland Medical Center. “We focused on two challenges that are problematic across the country — the overprescription of antibiotics and ineffective care pathways for acute sinusitis.”

According to the Centers for Disease Control and Prevention (CDC), each year at least 2 million people in the United States become infected with antibiotic-resistant bacteria. At least 23,000 of those people die as a result.

“Despite evidence that 90 percent of cases are viral, acute sinus infection is the fifth-leading cause of antibiotic prescription nationwide,” Dr. D’Anza says. “Studies show that over half of these prescriptions are unwarranted. By developing our own UH clinical guidelines, we saw an opportunity to not only promote antibiotic stewardship but also improve quality outcomes for our patients.”

Completed this spring, the CPG is based on a thorough review of medical literature and expert findings in the field, including the American Academy of Otolaryngology, the Infectious Diseases Society of America and specialists at UH Cleveland Medical Center.

“The evidence-driven recommendations provide an operational framework for UH practitioners to tailor appropriate medical therapy for each patient as efficiently and cost effectively as possible,” says Kenneth Rodriguez, MD, Chief, Rhinology and Skull Base Surgery at UH Cleveland Medical Center.

Practitioners are able to access the CPG through a patient’s electronic medical record. “We worked with our EMR team to codify the protocols so that when a physician enters the diagnosis of acute sinusitis, the care guide pops up to walk them through diagnostic criteria, first- and second-line antibiotics, adjunctive measures, and appropriate imaging orders,” Dr. D’Anza says.

A key component of the CPG addresses CT imaging. The recommendations clarify that scans should not be ordered for acute sinusitis unless there are concerns about complications related to the infection, such as orbital or intracranial extension.

“If patients have received adequate medical therapy and appropriate high-quality antibiotics but symptoms persist, then imaging is indicated,” Dr. Rodriguez says. “It is always best to scan after treatment so we capture a more accurate image within the sinuses. If the patient is a possible surgical candidate, we want physicians to use the CT volumetric order provided in the care guide because the scan is optimized for our image guidance system used to execute surgical plans.”

Selecting the most appropriate scan eliminates the burden and expense for patients who might otherwise be subjected to additional imaging and provides increased efficiency and cost containment for UH.

Since the CPG went live last spring, the rhinology division has been gathering data to measure outcomes. “We are looking at how the care guide has changed prescribing patterns,” Dr. D’Anza says. “Our preliminary data is favorable, indicating a decrease in prescription of inappropriate antibiotics as well as a reduction in CT scan orders by about 20 percent as compared to the year prior.”

In fact, the physicians are already beginning to present and publish some of their initial findings. Retrospective analysis of ongoing data collection for UH patients diagnosed with acute sinusitis will enable the team to continue to measure improvements in quality of care, efficiency and patient satisfaction.

“There is a shift in the healthcare landscape,” Dr. D’Anza says. “As we engage more with Accountable Care Organizations, reimbursement is increasingly based on quality measures — how well patients do and not how many procedures, scans or tests are ordered. Our overarching goal across the UH system is to meet our benchmarks to ensure that our patients are getting the best possible care.”


Contact Dr. D'Anza at and Dr. Rodriquez at