reported significant improvement in symptoms since the start of the study, versus 56% in the control group. The number needed to treat was 6 (95% confidence interval, 3 to 34; P = .02) for a reduction in symptoms at day 7.
Patients in both groups had similar rates of absenteeism, inability to perform usual activities, relapse and recurrence, and use of additional health care. Satisfaction with treatment was similar, as well.
No serious adverse effects occurred. Both groups reported similar frequencies (< 10%) of nausea, diarrhea, abdominal pain, or vaginitis.
WHAT’S NEW
Even severe sinusitis resolves without antibiotics
Previous studies recommended foregoing antibiotics for acute sinusitis, except when symptoms are severe. This study—in which more than half (52%) of patients in each group had symptoms rated severe or very severe—found no benefit to adding amoxicillin to supportive treatments.1 Antibiotics did not shorten the duration of illness, prevent relapse and recurrence, or improve satisfaction with treatment. The researchers found a statistically significant difference between groups on day 7 of 0.19 points, but no clinically meaningful difference (≥ 0.5) based on the SNOT-16 mean score.
CAVEATS
Guidelines, risk of complications may give reason to pause
The 2012 Infectious Diseases Society of America guidelines recommend amoxicillin with clavulanic acid as empiric therapy for acute bacterial rhinosinusitis.7 The findings of the study by Garbutt et al—conducted at a time when the incidence of beta-lactamase-producing organisms was low and amoxicillin was the treatment of choice—suggest otherwise.
Serious complications of sinusitis, such as brain abscess, periorbital cellulitis, and meningitis, can occur, however. Patients who deteriorate clinically or develop high fever or severe headache require close follow-up, which may include further diagnostic evaluation or consultation with an otolaryngologist. Evidence is lacking as to whether antibiotics prevent such complications.5
CHALLENGES TO IMPLEMENTATION
Managing patient expectations
Many patients with symptoms of acute rhinosinusitis think they need an antibiotic. Managing their expectations and providing instructions about supportive treatments are time consuming and may be
difficult.
Nonetheless, we’re optimistic: We think that most patients today are aware of the problems associated with antibiotic resistance and wary of “superbugs,” and will therefore be receptive to this practice change. Clinicians can help by reminding patients of the adverse effects of antibiotics and the natural course of rhinosinusitis, as well as by offering symptomatic treatments.
REFERENCES
1. Garbutt J, Banister C, Spitznagel E, et al. Amoxicillin for acute rhinosinusitis: a randomized controlled trial. JAMA. 2012;307:685-692.
2. Centers for Disease Control and Prevention. Summary health statistics for US adults: National Health Interview Survey 2010. January 2012. www.cdc.gov/nchs/data/series/sr_10/sr10_252.pdf. Accessed July 9, 2012.
3. Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg. 2007:137(3 suppl):S1-S31.
4. Hickner JM, Bartlett JG, Besser RE, et al; American Academy of Family Physians; American College of Physicians; American Society of Internal Medicine; Centers for Disease Control; Infectious Disease Society of America. Principles of appropriate antibiotic use for acute rhinosinusitis in adults; background. Ann Intern Med. 2001;134:498-505.
5. Ahovuo-Saloranta A, Borisenk OV, Kovanen N, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Sys Rev. 2008(2):CD000243.
6. Allen G, Kelsberg G, Jankowski TA. Do nasal decongestants relieve symptoms? J Fam Pract. 2003;52:714-724.
7. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54:e72-e112.
8. Zalmanovici A, Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev. 2009(4):CD005149.
9. Schumann A, Hickner, J. Patients insist on antibiotics for sinusitis? Here is a good reason to say “no.” J Fam Pract. 2008;57:464-468.
10. Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet. 2008;371:908-914.
11. Gill JM, Fleischut P, Haas S. Use of antibiotics for adult upper respiratory infections in outpatient settings: a national ambulatory network study. Fam Med. 2006;38:349-354.
12. Shehab N, Patel PR, Srinivasan A, et al. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis. 2008; 47:735-743.
ACKNOWLEDGEMENT
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
Copyright © 2012 The Family Physicians Inquiries Network. All rights reserved.
Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice. 2012;61(10):610-612.