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Skip the antibiotic in cases of acute sinusitis: report

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Antibiotic therapy in the first week of acute mild to moderate sinusitis is not worth it and should be avoided, conclude the authors of a report published in Archives of Internal Medicine.

Sinusitis is one of the most common diagnoses made in primary care, accounting for 20 million visits annually in the United States and 15% to 21% of annual antibiotic prescriptions, the authors note.

Yet, “the risks, harms, and costs outweigh whatever slight benefit may exist,” first author Dr. Stephen R. Smith from the Department of Family Medicine, Warren Alpert Medical School of Brown University in Providence, Rhode Island, told Reuters Health.

Last year, after soliciting input from more than 250 members, the National Physicians Alliance (NPA) came up with 15 recommendations it believes will help clinicians practice medicine more efficiently. (See Reuters Health story May 23, 2011). The treatment of acute mild to moderate sinusitis made the “Top 5” list.

The “Less is More” article by Dr. Smith and colleagues is the first in a series that will describe the evidence supporting the “Top 5” recommendations pertaining to adults. The authors reviewed the results of four meta-analyses of randomized trials published in the past 10 years that compared antibiotic treatment with placebo for acute mild to moderate sinusitis.

They did find that patients were significantly more likely to have improved or been cured one to two weeks after starting an antibiotic (compared to placebo). However, the differences were small, ranging from a 7% to 14% higher rate of improvement or cure with an antibiotic. The rate of complications and recurrence did not differ between antibiotic and placebo groups.

And antibiotics have considerable downsides, the researchers say. Side effects, mainly diarrhea, were 80% more common in the antibiotic groups compared with the placebo groups and were reported in 30% to 74% of treated patients.

“In addition to adverse effects, overuse of antibiotics can also harm population health by increasing rates of antibiotic resistance,” the authors note. “Avoiding antibiotics for acute sinusitis could reduce antibiotic adverse effects, antibiotic resistance and the cost of healthcare,” they say.

They also point to a cost-effectiveness analysis that showed that initial symptomatic (nonantibiotic) treatment was the most cost-effective strategy. Dr. Smith and colleagues note that the authors of this analysis concluded, based on the evidence, that “a 7- to 10-day course of watchful waiting before prescribing antibiotics would be reasonable, since most patients’ symptoms resolve without antibiotic treatment, and serious complications are rare.”

In their report, the Dr. Smith and colleagues say they “recognize that there may be special circumstances in which antibiotic treatment is appropriate, such as for patients with high fever, exquisite pain and tenderness over the sinuses, or signs of cellulitis.”

However, the majority of cases of acute mild to moderate sinusitis are caused by viruses and resolve without antibiotic treatment, they note. In an email to Reuters Health, Dr. Smith said the message to clinicians is straightforward: “Don’t prescribe antibiotics for uncomplicated acute sinusitis.”

In a companion essay published with the study, Dr. Smith offers suggestions on how to handle pressure from acute sinusitis patients who present convinced they need an antibiotic. They include finding out what the patient’s true concerns are; providing the patient with the information needed to understand your rationale for not prescribing an antibiotic; and providing a contingency plan if symptoms don’t improve.

The National Physicians Alliance has produced training videos that illustrate these tactics. They are available on YouTube. “The videos help physicians act as good stewards of finite clinical resources with a particular focus on the “Top 5” activities in primary care that could lead to better-quality care and reduced harms and costs if implemented,” Dr. Smith notes.

“A version of the videos was also produced specifically for patients. This can be played in waiting rooms. Well-informed consumers are valuable partners in their own care, helping their physicians make wise clinical decisions.”


Arch Intern Med 2012;172:510-15.