[Difficult-to-treat chronic rhinosinusitis-when the standard treatment is not effective and biologics are not available]. / Schwierig zu behandelnde chronische Rhinosinusitis ­ wenn die Standardtherapie nicht wirkt und Biologika nicht zur Verfügung stehen.

BACKGROUND: In recent years, significant improvements have been made in the treatment options for uncontrolled chronic rhinosinusitis (CRS) refractory to standard medical and surgical therapy. This is the result of a better understanding of the pathophysiology and the resulting development of biologicals for CRS with nasal polyps (CRSwNP). However, biologics are not (yet) available for all patients in Europe. OBJECTIVE: Based on the session "Difficult-to-treat CRS, when biologics are not available" at the 29th Congress of the European Rhinologic Society (ERS) 2023 in Sofia, Bulgaria, the treatment options for uncontrolled CRS with the exclusion of biologics will be discussed. MATERIALS AND METHODS: The content of the presentations "Is there a place for antibiotics?" "Indications for revision surgery," "Novel systemic treatment options," "Novel local treatment options," and "Phototherapy for nasal polyps" are outlined and supported by a review of the literature. RESULTS: Various treatment options are available for managing uncontrolled CRS, even if biologic treatments are unavailable. Treatment options for type­2 (T2) CRS include steroid rinses, repeated short-term oral steroids, steroid-eluting stents, and extended sinus surgery. In the case of nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NERD), acetylsalicylic acid (ASA) desensitization can be considered. Non-T2 endotypes or CRS without nasal polyps (CRSsNP) may benefit from several weeks of macrolides and xylitol rinses. CONCLUSION: To accurately assess the efficacy of second-line therapies for treatment of difficult-to-treat CRS within an endotype-specific framework, additional controlled clinical trials are needed that take into account the heterogeneity of CRS endotypes.

[Possibilities of usage of modern herbal medicinal product in the treatment of patients with acute viral rhinosinusitis]. / Vozmozhnosti primeneniya sovremennogo rastitel'nogo lekarstvennogo preparata v lechenii patsientov s ostrym virusnym rinosinusitom.

INTRODUCTION: The issues of epidemiology, etiopathogenesis, diagnostics and clinic of acute catarrhal rhinosinusitis are considered, the possibility of using the herbal medicinal product Sinupret extract in the treatment of patients with acute viral rhinosinusitis is substantiated. OBJECTIVE: To evaluate the efficacy and safety of using the drug Sinupret extract in patients with acute viral rhinosinusitis. MATERIAL AND METHODS: A comparative study of the efficacy and safety of clinical use in patients of the drug Sinupret extract in patients with acute viral rhinosinusitis was carried out in comparison with symptomatic treatment. RESULTS AND DISCUSSION: After analyzing and processing the results obtained using statistical methods for the main group, a faster rate of decrease in the severity of complaints (data with the use of the MSS visual analogue scale), the severity of inflammation in the nasal cavity and nasopharynx, the amount of discharge from the nose and its viscosity were confirmed. Restoration of respiratory function according to rhinomanometry and mucociliary transport according to the results of the saccharin test also occurred more quickly in patients of the main group compared to the control group. The effectiveness of using Sinupret extract is also confirmed by the results of photoplethysmography. CONCLUSIONS: The use of the drug Sinupret extract not only contributes to a more rapid improvement in the general well-being of patients and a decrease in the severity of complaints, but also leads to an improvement in the objective picture of the disease (rhinoscopy, the results of anterior active rhinomanometry, saccharin test) compared with the control group, favorably affects the quality life of patients, causes a decrease in economic and social costs against the background of the development of acute viral rhinosinusitis.

Chronic Rhinosinusitis.

Chronic rhinosinusitis (CRS) is an inflammatory disease of the nose and paranasal sinuses, with a prevalence of approximately 1% to 7%. It is defined by the presence of at least two cardinal symptoms (nasal blockage, obstruction, or congestion; anterior or posterior nasal drainage; facial pain or pressure; and hyposmia) for at least three consecutive months, with objective findings on imaging or nasal endoscopy. CRS can result in significant patient costs and lower quality of life due to severe fatigue, depression, and sometimes reduced cognitive function. The condition is categorized as primary or secondary and with or without nasal polyps. Treatment is directed at reducing symptoms, improving mucus clearance, reducing inflammation, enhancing ciliary function, and removing bacteria and biofilms from the nasal mucosa. First-line treatment comprises nasal saline irrigation and intranasal corticosteroids. Acute exacerbation of CRS is common and is defined as a transient worsening of symptoms. The role of oral antibiotics and oral corticosteroids for acute exacerbations is unclear. Optimal maintenance therapy can help alleviate exacerbations. Patients with refractory CRS that is not responsive to first-line treatment and patients with alarm symptoms should be referred to an otolaryngologist for further evaluation and consideration of surgical management. Identifying patients who have CRS with nasal polyps or comorbid conditions such as atopic dermatitis, asthma, or eosinophilic esophagitis is especially important to ensure they are referred to a specialist for consideration of biologic therapy.

[Experience of biological therapy in severe forms of chronic rhinosinusitis with nasal polyps in the conditions of regional healthcare]. / Opyt biologicheskoi terapii pri tyazhelykh formakh khronicheskogo polipoznogo rinosinusita v usloviyakh regional'nogo zdravookhraneniya.

Recurrent chronic rhinosinusitis with nasal polyps (CRSwNP) with a predominant Th2 endotype of inflammation, including associated with bronchial asthma and/or allergic rhinitis, aspirin triad, refers to diseases with an insufficient level of control, despite the use of a wide range of options for conservative and surgical treatment. OBJECTIVE: To analyze our own experience, clinical and organizational features of the application of the method of biological therapy in patients with severe forms of recurrent CRSwNP. MATERIAL AND METHODS: 25 patients with severe and moderate forms of CRSwNP were examined, who, in a round-the-clock hospital (model CSG 36.018) was treated with Dupilumab, in the form of subcutaneous injections of 300 mg/2 ml 1 every two weeks. The diagnosis was confirmed on the basis of anamnestic data, SNOT-22 quality of life questionnaires, visual endoscopic examination, evaluation of CT data (Lund-Mackay scale), laboratory data. The effectiveness of treatment was monitored after 16 weeks, based on endoscopic examination data, evaluation of CT and SNOT-22 data. In 3 observations, a study of pathomorphological material for tissue eosinophilia was performed. RESULTS: The duration of the course of treatment ranged from 10 to 56 weeks. The most striking clinical effect was observed for signs such as sense of smell and nasal breathing (in some cases-after the first injection). The degree of regression of polyps according to CT and endoscopic examination was more prolonged in time, the same dynamics was observed in the level of total IgE. In a number of patients, the phenomenon of eosinophilia growth was observed against the background of treatment (with regression of clinical symptoms). Pathomorphological examination confirmed a high level of tissue eosinophilia as one of the fundamental signs of Th2 inflammation. One patient with concomitant chronic tubar dysfunction had an improvement in hearing. All patients with AD noted a subjective improvement in disease control (a decrease in the frequency and severity of choking attacks). The cancellation (break in treatment) of treatment was accompanied by a gradual return of symptoms in all patients at various times. CONCLUSIONS: Patients who have not achieved an acceptable level of control of CRSwNP,that meets the criteria of Th2 inflammation can be considered as candidates for the use of targeted biological therapy. With strict compliance with the selection criteria, there is a good clinical effect, primarily in relation to nasal symptoms (sense of smell and nasal breathing) and improved control of asthma symptoms.

Rhinosinusitis: clinical-based phenotyping.

Rhinosinusitis (RS) is a common disease and is currently classified into two main types: acute RS (ARS) and chronic RS (CRS), which in turn includes CRS with or without nasal polyps. Different guidelines consider this classification. However, in clinical practice, other phenotypes exist. The current article would propose new clinical-based phenotyping of RS, including the following clinical phenotypes: simple catarrhal RS, Acute RS, acute bacterial RS, severe (complicated) acute RS, chronic RS, and recurrent chronic RS. Treatment strategy should be tailored considering the clinical phenotype and could include phytomedicines, intranasal non-pharmacological remedies, and local bacteriotherapy. In conclusion, RS requires thorough diagnostic work-up, and the therapeutic approach should be mainly based on appropriate management.

[The understanding of chronic rhinitis in traditional Chinese medicine and the definition of nasal obstruction disease].

This paper reports on review of the conceptual cognition and definition of chronic rhinitis in traditional Chinese medicine (TCM). Diseases with nasal congestion as the main symptom were recorded in The Yellow Emperor's Inner Classic (Huang Di Nei Jing) and Medical Bamboo slips of Wu Wei(Wu Wei Yi Jian), but these diseases had not been given names at that point in time. Chronic rhinitis and acute rhinitis had not been distinguished clearly. Some symptoms, in ancient Chinese medical books, indicated some possibility as those of chronic rhinitis, such as "bi weng"(), "stuffy nose"(), "anosmia" (), "nasal obstruction"(), "stuffy nose with anosmia"() and " poor nasal passages" ().In the first half of the last century, "biyuan"(), "biweng" () and "stuffy nose"() were classified at the symptoms of chronic rhinitis with the same names in traditional Chinese medicine. "Biyuan" was widely used at that time, but was gradually eliminated for the lack of semantic meaning. In the 1970s, "nasal obstruction" was proposed by many textbooks as the name of TCM for chronic rhinitis. In 1980, "nasal obstruction disease"() was finally specified as the formal name by Otorhinolaryngology of TCM (the 4th edition), the national unified textbook. This term has been widely accepted in the field of traditional Chinese medicine, driven by the united textbooks and clinical guidelines, while it is still insufficient in the perspective of meaning and science. The process of normalisation of "nasal obstruction disease" shows that the name of chronic rhinitis in ancient Chinese medicine is not equivalent to its term in modern medicine. It also suggests that the comparison of disease names between traditional Chinese medicine and western medicine must be fully investigated. It is necessary to understand the differences between ancient and modern connotations of terminology when reading and using ancient Chinese medicine literature.

Usefulness of bilateral mucoplasty plus reboot surgery in severe type-2 chronic rhinosinusitis with nasal polyps.

BACKGROUND: Although extended endoscopic sinus surgery (ESS) constitutes an alternative approach in patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP), the surgical techniques proposed so far do not allow for an optimal control of the disease. This study introduces bilateral mucoplasty as a complementary technique to extended ESS such as reboot surgery, analyzing its benefits in healing and quality of life (QoL). METHODS: Patients diagnosed with severe Type-2 CRSwNP were selected for a prospective cohort study in two surgery groups: reboot surgery plus bilateral mucoplasty versus reboot surgery only. In the first group, an autologous endonasal mucosal graft from the nostril floor was placed bilaterally onto the ethmoidal roof. Endoscopic, radiological and QoL outcomes were compared before and one year after surgery between the two groups using Modified Lund Kennedy (LKM), Meltzer and Lund Mackay (LM) scores, and the Sino-Nasal Outcome Test 22 (SNOT-22). RESULTS: 64 patients with homogeneous baseline characteristics were included: 17 patients underwent a reboot surgery plus a bilateral mucoplasty and 47 a reboot surgery only. LKM, Meltzer and SNOT-22 scores showed significant differences before and after surgery in both groups, with higher improvement in the mucoplasty group. A greater mean improvement of 20.5 ± 6.4 points in SNOT-22 change was associated with bilateral mucoplasty. CONCLUSION: Bilateral mucoplasty plus reboot surgery constitutes a useful surgical resource in Type-2 CRSwNP patients, showing improved endoscopic, radiological and QoL outcomes one year after surgery. Further studies are needed to determine their long-term benefits.

A Comparison of International Guidelines for Rhinosinusitis.

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), latest version EPOS2020, and the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS), latest version ICAR-RS-2021, assimilate thousands of articles on the topic of rhinosinusitis. Encompassing scores of subtopics and relying on the perspectives of many international experts, EPOS2020 and ICAR-RS-2021 reduce the existing data into consumable formats and create evidence-based recommendations. The approaches and findings are similar in many respects but have significant differences. This clinical commentary, authored by some of the principal authors of these documents, compares and contrasts EPOS2020 and ICAR-RS-2021, examining methodology, diagnostic and treatment recommendations, and each document's emphases. This commentary demonstrates that, through somewhat differing methodologies, the 2 documents arrive at largely similar conclusions. Those who care for patients suffering from rhinosinusitis will find the documents complementary and valuable in their differences as much as in their similarities.

[Comparative efficacy of various treatment regimens for children 2-5 years old with symptoms of acute viral rhinosinusitis]. / Sravnitel'naya effektivnost' razlichnykh skhem lecheniya detei 2­5 let s simptomatikoi ostrogo virusnogo rinosinusita.

In an open, randomized prospective comparative clinical study in parallel groups of patients with a diagnosis of acute respiratory infection, acute rhinosinusitis, 107 children aged 4-5 years took part. The purpose of this study was to compare the effectiveness of various treatment regimens for acute viral rhinosinusitis in children. We compared the treatment effectiveness of acute viral rhinosinusitis using the herbal medicine Sinupret in the form of oral drops, standard treatment and standard treatment supplemented with topical antibacterial drugs. The objectivity of treatment effectiveness evaluation was based on the complaints' dynamics, the changes' presence in the mucous membrane of the nasal cavity within 10 days: at the initial visit, after 3 days, on the 7th and 10th days after the initial examination. A follow-up visit was also scheduled for the 14th day. The analysis of the obtained data revealed that the Sinupret usage in the complex treatment of children with viral etiology acute rhinosinusitis contributes to a more pronounced positive symptoms' dynamics compared to children who did not receive Sinupret. Sinupret eliminates mucostasis, which contributes to a faster restoration of the drainage and ventilation function of the auditory tube, restores mucociliary clearance, improves the condition and well-being of children, improves the effectiveness of therapy and shortens the treatment time.

Rhinitis 2020: A practice parameter update.

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

Inflammation, infection, and allergy of upper airways: new insights from national and real-world studies.

The upper airways (UA) should be considered as a functional unit. Current functional anatomy divides URT in three, mutually dependent, "junction boxes": i) the ostio-meatal complex (OMC), ii) the spheno-ethmoidal recess (SER), and iii) the rhinopharynx (RP). Correct ventilation and effective mucociliary clearance of these sites significantly affect the healthy physiology of the entire respiratory system. The OMC, SER, and RP obstruction is the first pathogenic step in the inflammatory/infectious cascade of UA disorders. The inflammation of the respiratory mucosa is the main pathogenic factor for airway obstruction. Moreover, bacterial biofilm (a strategy modality of bacterial survival) is an important local cause of systemic antibiotic ineffectiveness, recurrent infections, and antibiotic resistance. Health microbiota guarantees UA wellness; on the contrary, dysbiosis promotes and worsens UA infections. Allergy, namely type 2 inflammation, is a common cause of UA obstruction such as promoting in turn infections. Fiberoptic endoscopy is a mandatory diagnostic tool in clinical practice. Nasal cytology, mainly concerning flow cytometry, allows defining rhinitis phenotypes so allowing a precision medicine approach. Several conventional therapeutic approaches are available, but efficacy and safety should be ever properly considered before the prescription. Also, complementary medicine plays a fruitful role in the management of UA diseases. National and real-world studies are reported and discussed as they may be useful in daily clinical practice.

Budesonide nasal irrigation improved Lund-Kennedy endoscopic score of chronic rhinosinusitis patients after endoscopic sinus surgery.

PURPOSE: Budesonide improves the prognosis of chronic rhinosinusitis (CRS). However, few reports have examined whether its use for nasal irrigation, compared to normal saline, improves the prognosis of patients after endoscopic sinus surgery (ESS). We compared the effects of nasal irrigation with budesonide and normal saline in CRS patients after ESS. METHODS: Sixty CRS patients who had undergone ESS were randomly divided into an experimental group (30 patients), which used budesonide nasal irrigation, and a control group (30 patients), which used normal saline nasal irrigation. All patients received regular follow-up evaluations and were assessed via questionnaires, including the Lund-Kennedy endoscopic score (LKES), the symptom visual analog scale (VAS), the 22-item Sino-Nasal Outcome Test (SNOT-22), the Short-Form 36-Item Questionnaire (SF-36), the Self-Rating Anxiety Scale (SAS), the Self-Rating Depression Scale (SDS) and a side effects scale. RESULTS: Scores of polyposis, mucosal edema, secretions and total score of LKES; VAS scores of nasal blockage, hyposmia and rhinorrhea; and SNOT-22 results in both groups were significantly improved 3 months after ESS. Scores of polyposis, mucosal edema, secretions and scarring and total score of LKES in experimental group were significantly better than in control group 3 months after ESS. No significant differences were observed in SF-36, SAS or SDS before or 3 months after ESS within or between the two groups. The side effects of the two groups were not significantly different. CONCLUSIONS: Nasal irrigation improved the prognosis of CRS patients after ESS. Budesonide nasal irrigation had a better effect than normal saline nasal irrigation.

Saline nasal irrigations for chronic rhinosinusitis: From everyday practice to evidence-based medicine. An update.

Saline nasal irrigations (SNIs) are often recommended as an additional non-pharmacological treatment for adults with chronic rhinosinusitis (CRS), for which it could even be considered a first-line treatment. However, there is a wide range of different SNI protocols. The aim of this article is to review the published literature regarding all of the potential therapeutic effects of SNIs in adult CRS patients who had not undergone sinus surgery and clarify the role of the various saline nasal solutions and protocols (particularly the volume, frequency and duration of treatment), and describe the nasal devices used. A search was made of the PubMed, Google Scholar and Ovid databases using the key words 'saline nasal irrigation' and 'chronic rhinosinusitis', or medical subject headings. The search identified 11 studies involving 663 patients. There was no consensus about but substantial agreement concerning the frequency and duration of treatment, the type of device, and the amount of solution to be used when managing CRS. A hypertonic solution with the addition of the natural minerals and oligo-elements found in seawater and some thermal waters may be associated with greater clinical benefit in terms of endoscopic scores and mucociliary clearance than isotonic solutions. Further studies are required to compare the different forms of SNI and define SNI protocols and nasal devices, while considering patient compliance.

Phytomedicines in Acute Rhinosinusitis: A Prospective, Non-interventional Parallel-Group Trial.

INTRODUCTION: The objective of this prospective, multicenter, parallel-group, non-interventional clinical trial (NIT) was to characterize the effectiveness of a treatment with the phytomedicines ELOM-080 and BNO 1016 in patients with acute rhinosinusitis (ARS). METHODS: A total of 228 patients suffering from ARS took part in this NIT and were treated for a maximum of 14 days with either BNO 1016 or ELOM-080. Focus was on improvement of rhinosinusitis-associated pain/discomfort and nasal congestion in real-life conditions of primary care setting, as assessed by numeric and verbal rating scale, and five-point Likert scale. RESULTS: The course of the key ARS symptom facial pain demonstrated a faster recovery in patients with ELOM-080, when compared to BNO 1016. ELOM-080 tended to be superior for several ancillary criteria and induced significantly higher patient satisfaction with regard to the improvement of feeling of general illness. Physicians assessed both products to be very effective and well tolerated. Adverse drug reactions classified as gastrointestinal disorders occurred in both groups to a comparable extent. CONCLUSION: This trial demonstrated comparable effectiveness of a therapy of ARS with the phytomedicines ELOM-080 and BNO 1016, although the treatment with ELOM-080 resulted in a more rapid and more complete recovery in ARS key symptoms and tended to be superior for several ancillary criteria. Both treatments were well tolerated. TRIAL REGISTRATION NUMBER: NIS-6471. FUNDING: G. Pohl-Boskamp GmbH & Co. KG.

Overuse of diagnostic tools and medications in acute rhinosinusitis in Spain: a population-based study (the PROSINUS study).

OBJECTIVES: Acute rhinosinusitis (ARS) has a high incidence. Diagnosis is clinical, and evolution is mostly self-limited. The aim of this study was to describe the sociodemographic characteristics and use of diagnostic tools and medications in patients with ARS. DESIGN: This is a prospective observational study in real-life clinical practice. SETTING: Patients with clinical diagnosis of ARS (n=2610) were included from ear, nose and throat clinics in Spain. A second visit at resolution was done. PARTICIPANTS: Patients were classified according to the duration of symptoms: viral ARS (≤10 days), postviral ARS (>10 days, ≤12 weeks) and chronic rhinosinusitis (>12 weeks). MAIN OUTCOME MEASURES: Sociodemographic characteristics, symptoms, disease severity, quality of life (Sino-Nasal Outcome Test-16), used diagnostic tools and medications, and the management performed by primary care physicians (PCPs) and by otorhinolaryngologists (ORLs) were assessed. RESULTS: Of the patients 36% were classified as having viral ARS, 63% postviral ARS and 1% as chronic rhinosinusitis. Working in a poorly air-conditioned environment was a risk factor (OR: 2.26, 95% CI 1.27 to 4.04) in developing postviral ARS. A higher number of diagnostic tools (rhinoscopy/endoscopy: 80% vs 70%; plain X-ray: 70% vs 55%; CT scan: 22% vs 12%; P<0.0001) were performed in postviral than viral cases. PCPs performed more X-rays than ORLs (P<0.0001). Patients, more those with postviral than viral ARS, received a high number of medications (oral antibiotics: 76% vs 62%; intranasal corticosteroids: 54% vs 38%; antihistamines: 46% vs 31%; mucolytic: 48% vs 60%; P<0.0001). PCPs prescribed more antibiotics, antihistamines and mucolytics than ORLs (P<0.0068). More patients with postviral than viral ARS reported symptoms of potential complications (1.5% vs 0.4%; P=0.0603). Independently of prescribed medications, quality of life was more affected in patients with postviral (38.7±14.2 vs 36.0±15.3; P=0.0031) than those with viral ARS. ARS resolution was obtained after 6.04 (viral) and 16.55 (postviral) days, with intranasal corticosteroids being associated with longer (OR: 1.07, 95% 1.02 to 1.12) and phytotherapy with shorter (OR: 0.95, 95% CI 0.91 to 1.00) duration. CONCLUSIONS: There is a significant overuse of diagnostic tools and prescribed medications, predominantly oral antibiotics, by PCPs and ORLs, for viral and postviral ARS.

Failure of a Best Practice Alert to Reduce Antibiotic Prescribing Rates for Acute Sinusitis Across an Integrated Health System in the Midwest.

BACKGROUND: Antimicrobial resistance is a growing concern, and in recent years, there has been increased interest in ambulatory antimicrobial stewardship. Acute rhinosinusitis (ARS) is one of the most common outpatient diagnoses that results in an antibiotic prescription. OBJECTIVE: To determine if a best practice alert (BPA) will affect the percentage of oral antibiotic prescriptions for adults with ARS. METHODS: A prospective, pre/post study was initiated to evaluate the percentage of oral antibiotic prescriptions for ARS in 117 primary care clinics in the Midwest. Included in the study results were 16,570 adults who had an office visit for ARS: 8,106 patients from December 1, 2015, to February 28, 2016, were in the pre-intervention group without an active BPA, and 8,464 patients from December 1, 2016, to February 28, 2017, were in the post-intervention group when the BPA was active. The primary outcome was the number of oral antibiotic prescriptions for ARS compared with the number of office visits for ARS in the pre- and postintervention groups. RESULTS: The percentage of oral antibiotics prescribed for the pre- and postintervention groups were 94.8% and 94.3%, respectively (P = 0.152). The BPA displayed for 7,780 visits, prompting discontinuation of an antibiotic for 10 (0.1%) visits in the postintervention group. CONCLUSIONS: This study suggests that, although an electronic alert may be attractive to facilitate antimicrobial stewardship, it may be ineffective. These results warrant alternative measures to facilitate ambulatory antimicrobial stewardship. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest to declare. Study concept and design were contributed by Hansen, D. Leedahl, and N. Leedahl. Hansen and N. Leedahl took the lead in data collection, with assistance from Carson and D. Leedahl. Data interpretation was performed by all the authors. The manuscript was written by Hansen, along with the other authors, and revised by all the authors.