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Moratorium urged on lengthy empiric antibiotics for chronic rhinosinusitis

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Symptoms considered typical of chronic rhinosinusitis are often nonspecific and do not warrant antibiotic treatment, according to findings reported in Clinical Infectious Disease online November 22.

“We recommend a moratorium for the widespread practice of a prolonged course of empiric antibiotics in patients with presumed CRS (chronic rhinosinusitis),” the authors conclude.

Dr. Victor L. Yu, at the University of Pittsburgh, Pennsylvania, and colleagues point out that chronic rhinosinusitis is traditionally thought to be a sequela of unresolved bacterial infection, and antibiotic therapy is often initiated based on typical symptomatology such as decreased sense of smell or face pain.

The team investigated 125 patients with classic symptoms of chronic rhinosinusitis, using CT scans of the sinuses to diagnose the condition definitively. On that basis, 75 of the patients had radiographic evidence of rhinosinusitis while 50 had normal CT scans.

A decreased sense of smell was more prevalent in the CT-positive group than the group with normal CT findings (79.2% vs 48.7%; p=0.003), the investigators found.

On the other hand, other typical symptoms (headache, facial pain, and sleep disturbance) were actually significantly more common in patients with normal CT scans than those with abnormalities (p<0.05), according to the report. “This paradoxical finding raises the distinct possibility that many patients with symptomatology classic for CRS are not actually infected,” the authors suggest.

On nasal endoscopy, mucopurulence was absent in all the patients with normal sinus CT scans, but present in 18 (24%) of those in the CT-positive group.

The researchers asked patients about antibiotic use in the past year and whether it was helpful. Usage of antibiotics was 60% in the group with abnormal CT results and 52% in those with normal scans. Among those who received antibiotics, symptomatic improvement was reported by 80% and 81% in the two groups, respectively, Dr. Yu and colleagues report.

“If CRS was truly an infection, one might expect that the clinical response following antibiotic therapy would be superior in patients who truly had CRS, they argue.

Hence, they conclude: “For patients who are to be considered for prolonged antibiotic therapy, we recommend that nasal endoscopy with cultures be performed. Antibiotics can be given if mucopurulence is seen.”

The author of an accompanying editorial observes, “This report reemphasizes the importance of making the correct diagnosis before administering treatment, a universal but regrettably too often forgotten rule in medical practice.

Reference:

Prospective Observational Study of Chronic Rhinosinusitis: Environmental Triggers and Antibiotic Implications

Clin Infect Dis 2011.