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Sinusitis and antibiotics

Posted by medconsumers on February 18, 2012

“The great secret of doctors is that most things get better by themselves; most things, in fact, are better in the morning.” This mid-20th century observation by the renowned scientist Lewis Thomas came tomind as I read a new study of people with acute sinusitis. It found that those who received no treatment recovered in the same amount of time as those taking antibiotics. Yes, antibiotics have long been the standard treatment, but their purported benefit has never been proven definitively.

The new study was designed to see whether the distressing symptoms of acute sinusitis like pain, fever, cough, and nasal congestion are alleviated faster with amoxicillin.The 166adult participants were randomly assigned to take either a ten-day course of amoxicillin (1500 mg/daily) or a placebo (three times/daily).  The participants kept records of their symptoms.

By the third and tenth day of treatment, there was no difference in symptoms between the people on amoxicillin and the people taking nothing (i.e., placebos).  And no serious adverse events occurred in either group. This study was funded by a grant from the U.S.  National Institute of Allergy and Infectious Diseases and published this week in the Journal of the American Medical Association (JAMA).

“[The use of] antibiotics doesn’t get patients feeling better quicker, prevent relapse, or prevent complications.  There was no observed benefit for the majority of patients,” said co-author, Jay Piccirillo, MD, Washington University, St. Louis, in a video on the JAMA website. “The most likely cause of sinusitis is viral,” he added, referring to the fact that antibiotics are effective only against bacterial infections.

Still, the study’s conclusion leaves the door open for the possibility that not all will benefit from avoiding antibiotics: “It is important to note that patients with symptoms indicative of serious complications were excluded from this trial and likely need a different management strategy.”

Jane Garbutt, MB, ChB, the lead author of the study, was asked about the small minority whose sinusitis is due to a bacterial infection. “There is no doubt that some people with acute sinusitis have a bacterial infection and these patients would likely benefit from antibiotic treatment.  Unfortunately, there are no disease characteristics or diagnostic test that can accurately identify these patients at the moment. We used the clinical characteristics recommended to make a presumptive diagnosis of bacterial infection in our study, but they failed to identify  those patients who would benefit from antibiotic treatment,” she explained in a phone interview.  “80% of the people in our study were better by the 10th day and many were improved by day 3—that is, day 10 of symptoms.  To avoid unnecessary antibiotic treatment, we suggest watchful waiting and symptomatic treatment with reassessment if the symptoms do not improve as expected or get worse.”

Antibiotic resistance is a major problem worldwide, which has led to some changes in the way doctors prescribe antibiotics. The University of Washington researchers wrote that physicians in the U.S. have been slower to adopt a strategy used widely in Europe and found to be effective in a Dutch study. Called “delayed antibiotic prescriptions”, the person with symptoms of sinusitis leaves the doctor’s office with an antibiotic prescription but is told to take the drug only if a fever develops or the symptoms do not resolve after three days.

The researchers also called for better therapies for symptom relief. “Intranasal steroids have not proved to be as widely effective as first hoped but may reduce symptoms for some patients with mild disease,” they wrote. “Promising alternative treatments such as nasal irrigation need further investigation.”

For more information

Read my 2007 article about a home remedy for sinusitis called nasal irrigation. Click here

Read about earlier sinusitis studies at one of my favorite websites called TheNNT.com   Click here its summary of antibiotics for sinusitis  for a 2010 review of five randomized trials that found a “mild benefit” to antibiotics for acute sinusitis.  Scroll down to the “Caveats” to see how difficult it is for doctors to determine whether an infection is viral or bacterial.  And how uncertain is the benefit of antibiotics even for bacterial sinusitis.

Maryann Napoli, Center for Medical Consumers©

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