Source: Lemiengre MB, van Driel ML, Merenstein D, Young J, De Sutter AI. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2012 Oct 17;10:CD006089. doi: 10.1002/14651858.CD006089.pub4. Review. PubMed PMID: 23076918.
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Efficacy Endpoints: Reduction of sinusitis symptoms
Harm Endpoints: Adverse medication events
Narrative: Acute rhinosinusitis is a common infection of the nasal mucosa and paranasal sinuses, typically diagnosed based on symptoms (most often purulent nasal drainage and facial pain). Most cases are viral in etiology and present as an uncomplicated upper respiratory infection, however antibiotic use is common. This Cochrane review examined data on antibiotic benefits and harms in adult populations clinically diagnosed with rhinosinusitis.
Eight high quality randomized trials including 1687 adult participants comparing placebo to antibiotic treatment were included. Four studies evaluating cure rate at seven days found no difference (47% both groups; OR 1.1, .95CI: 0.8-1.4) although cure rate between seven and 14 days was higher for those receiving antibiotics (73% vs 64%, OR 1.5, .95CI: 1.0-2.0, NNT 11). The odds ratio for overall treatment effect of antibiotics was 1.25 (.95CI 1.0 -1.5, NNT 18).
Analgesic and decongestant use was the same, however subjects in the antibiotic group were less likely to experience treatment failure (i.e. receive intervention for ongoing symptoms) with an OR of 0.5 (.95CI: 0.4 to 0.7, NNT of 20). The one serious illness-related event, a brain abscess, occurred in the antibiotic group.
There was an increase in side effects (largely gastrointestinal) in those treated with antibiotics, OR 2.1 (.95CI: 1.6-2.8, NNH 8). The NNH specifically for diarrhea was 18.
Caveats: This review focused on acute rhinosinusitis evaluated in general practice. Studies using radiology or microbiology assessments for diagnosis were excluded, which limits generalizability of this review (see Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis for relevant data from studies predominantly enrolling patients diagnosed by radiographic means), although this review is likely relevant to a preponderance of patients treated in everyday practice. There was a range of antibiotic regimens and definitions for cure across studies, and the eight studies reporting overall cure measured endpoints variably at 7, 10 and 14 days. The cure endpoint at 14 days (NNT 11 for antibiotics) may arguably be the most complete course of antibiotics, and it is notable that 5.2% more placebo group subjects were subsequently prescribed antibiotics for worsening symptoms or treatment failure (NNT 19 for antibiotics).
It is interesting that pooled studies of subject-declared cures supported the small benefit of antibiotics while those with clinician-diagnosed cures found no benefit, and suggests that a patient-centered approach would endorse a small benefit for sinusitis symptoms in favor of antibiotics. However this benefit comes at a cost. Given that neither the placebo nor antibiotic group found serious adverse events to be a problem, the use of antibiotics to reduce symptoms must be weighed against side effects. Ultimately, this balance has led us to classify this review as ‘Black’: for clinically diagnosed sinusitis the identifiable utility of antibiotics is to reduce respiratory symptoms in a small percentage of patients, while trading this for (arguably more vexing) gastrointestinal symptoms in a larger percentage of patients.
Author: Christina Chao, MD
Published/Updated: January 8, 2013
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