Are antibiotics appropriate for the treatment of acute sinusitis in adults?

BACKGROUND: Antibiotic use is an important factor in the recent dramatic increase in antibiotic-resistant Streptococcus pneumoniae. Although most outpatient antibiotic prescriptions are for upper respiratory tract infections (URIs), systematic reviews have shown that these drugs have either a very modest benefit or no benefit in the treatment of common URIs. Because of the high rate of antibiotic use and growing resistance, the Centers for Disease Control and Prevention began a program to educate patients and physicians about the dangers of overuse. They first turned their attention to pediatric infections and then sponsored the development of guidelines for appropriate antibiotic use for URIs in adults. Numerous organizations, including the American Academy of Family Physicians (AAFP) and the American College of Physicians–American Society of Internal Medicine have endorsed these guidelines. This review will only cover the recommendations for acute sinusitis.

POPULATION STUDIED: These guidelines apply to nonhospitalized patients with acute sinusitis of a known or unknown etiology.

STUDY DESIGN AND VALIDITY: These are well-developed evidence-based practice guidelines for the appropriate use of antibiotics for acute sinusitis. When appropriate, the authors graded the evidence for the principles,¹ using a modification of the method proposed by Sackett and colleagues.² The authors addressed 3 specific questions (How is the diagnosis established? What is the likelihood that the symptoms are bacterial in origin? Is antibiotic therapy indicated?).² Although the specific search criteria are not given, the evidence for the reviews is based on Cochrane Collaboration and Agency for Healthcare Research and Quality systematic reviews. The authors updated the literature search for these reviews through March 2000. The recommendations were reviewed by experts in the field and several national organizations including the AAFP. The guidelines have not been subjected to testing.

OUTCOMES MEASURED: Patient-oriented outcomes for acute sinusitits (eg, resolution of symptoms at 14 days) were examined.

RESULTS: Sinus radiographs are not recommended for uncomplicated sinusitis (grade B evidence of no benefit). For patients with acute bacterial sinusitis (<2% of patients with a URI have a bacterial cause) and mild or moderate symptoms, antibiotics are not required (grade A evidence of no benefit). On the basis of the results of 3 meta-analyses, broader spectrum antibiotics offer no additional benefit. In patients with severe or persistent moderate symptoms, narrow spectrum antibiotics, such as amoxicillin, should be used.