Source: Lemiengre MB, van Driel ML, Merenstein D, Liira H, Mäkelä M, De Sutter AIM. Antibiotics for acute rhinosinusitis in adults. Cochrane Database of Systematic Reviews 2018, Issue 9. Art. No.: CD006089. DOI: 10.1002/14651858.CD006089.
Study Population: 3057 participants suspected of acute rhinosinusitis (symptoms for 30 days or less) from 15 trials in ambulatory care settings
Efficacy Endpoints: Clinical cure (resolution or improvement of major symptoms)
Harm Endpoints: Adverse effects from antibiotic use
Narrative: Acute sinusitis is a common condition encountered by clinicians in the ambulatory and emergency department setting. It is characterized by inflammation of nasal passages and sinuses, resulting in purulent nasal discharge, sinus tenderness, and facial pain. A majority of these cases are caused by a viral or self-limiting bacterial infection neither of which require antibiotics for treatment.1 Despite longstanding guidelines that recommend limiting the use of antibiotics to a small subset of patients, a majority of patients continue to be prescribed antibiotics.2
This Cochrane Review discussed here3 examined data on benefits and harms associated with the use of antibiotics in adults diagnosed with acute rhinosinusitis (symptoms for 30 days or less). The rate of cure without any antibiotic use was 46% after one week and 64% after two weeks. The definition of cure varied depending on study but in most cases was defined as resolution or improvement of major symptoms.
The Cochrane review categorized the participants into three groups: those with clinically-diagnosed, radiographically diagnosed, and computerized tomography (CT)-diagnosed rhinosinusitis. The use of antibiotics was associated with a significant increase in the cure rate of clinically diagnosed rhinosinusitis (odds ratio [OR]: 1.25, 95%CI, 1.02 to 1.54; absolute risk difference [ARD]: 5%; Number-needed-to-treat [NNT]: 19; high quality evidence), as well as radiographically diagnosed (OR: 1.57, 95% CI, 1.03 to 2.39; ARD: 10; NNT:10; moderate quality evidence) and CT diagnosed rhinosinusitis (OR: 4.89, 95%CI, 1.75 to 13.72; ARD:25%, NNT:4; moderate quality evidence; one trial).3 Overall, antibiotics increased the rate of cure by 6% (absolute risk increase) corresponding to a number-needed-to-treat of 17 (OR: 1.38, 95%CI, 1.15 to 1.65).3
Adverse events were significantly increased with the use of antibiotics (OR:2.21, 95%CI, 1.60 to 2.77; ARD: 12.5%; number-needed-to-harm [NNH]:8). The type of adverse events varied with the most common being gastrointestinal effects such as diarrhea.3
Secondary outcomes such as resolution of purulent secretion, resolution of pain, illness duration, and restriction of daily activities could not be quantitatively assessed due to data heterogeneity.
Caveats: The findings here might not be generalizable to all patients with sinusitis. The meta-analysis excluded or did not consider patients with severe symptoms, pediatric patients, immunocompromised patients, or those with chronic symptoms.
There was a higher cure rate in patients diagnosed by CT scan. But the usefulness and generalizability of this particular finding are limited by the fact that the data were derived from only a single trial. Moreover, imaging is not routinely used in patients with acute rhinosinusitis, and patients who require imaging (e.g. those with chronic sinusitis) may respond differently to antibiotics than the patients more commonly seen in emergency departments or outpatient offices. For most patients, the cost and the risk of radiation exposure outweigh the benefit of routine imaging for diagnosis, even if in fact this is useful in identifying individuals who are more likely to be helped by antibiotics.
Some of the more serious adverse effects of antibiotics that are uncommon or more difficult to quantify (e.g. allergic reactions, C. difficile infection, and the development of antibiotic resistance) were not reported in this analysis.
American Academy of Otolaryngology-Head and Neck Surgery4 and Infectious Disease Society of America5 both recommend observation and symptomatic management similar to that of acute viral rhinosinusitis for acute uncomplicated sinusitis. These guidelines recommend antibiotics in patients who fail symptomatic management after approximately 7 days.4, 5
We thus assign a color recommendation of Red (risk of harm exceeds potential benefit) for this treatment because of the relatively high rate of reported adverse effects and the high likelihood of resolution of symptoms with supportive care and symptomatic management. Our recommendation is in line existing guidelines for selective antibiotic use in this condition.
Author: Nathan Franck, MD; Shahriar Zehtabchi, MD
Published/Updated: May 3, 2019
The title bar is color-coded with our overall recommendation.