Chronic sinusitis on the rise: How to avoid it

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Chronic sinusitis is being diagnosed with increasing frequency. In the last 15 years doctor visits for adults with this condition have tripled and for children, they have more than doubled. The standard 10-day course of antibiotics is not working for many people who find themselves going from one antibiotic prescription to another without relief. The pharmaceutical industry's response has been to go back to the lab and create even more powerful versions of antibiotic drugs designed to kill the bacteria present in sinusitis. The bacteria's response to the introduction of these new antimicrobial drugs has been the creation of new drug-resistant strains. The use of endoscopic surgery to drain the sinuses, the treatment of last resort, has shown a major increase in the last few years.

Erdem I. Cantekin, Ph.D., professor of otolaryngology at the University of Pittsburgh School of Medicine, believes that the increase in chronic sinusitis is due to overuse of antibiotics and the best protection is to avoid them. In a telephone interview, Dr. Cantekin explained that acute sinusitis is a self-limiting illness, which means it will go away with or without treatment.

By avoiding antibiotics, he explained that the condition is less likely to become chronic. "The sinus pain is caused by the pressure of the congestion, which can be more safely alleviated with saline (salt water) nose drops and seeking a humid environment with a humidifier. If people have allergies, a drug like Seldane can be helpful." Most importantly, Dr. Cantekin points out that there is no scientific evidence to support the prescribing of antibiotics to children with acute sinusitis.[*] (The only randomized, placebo-controlled clinical trial involving adults with acute sinusitis showed equivocal results in the group taking antibiotics.) As for chronic sinusitis, Dr. Cantekin advises people who believe they have this condition to undergo a CAT scan to make sure the diagnosis is correct.

Robert Ruben, M.D., takes more of a middle-ground approach to antibiotics, advising their selective use in certain cases. As professor and chairman of the otolaryngology department at the Montefiore Medical Center of the Albert Einstein College of Medicine, Bronx, New York, Dr. Ruben says that he sees much confusion over the exact definition of chronic sinusitis. In a telephone interview, Dr. Ruben said, "The diagnosis can be given to anyone from the person with the occasional runny nose with postnasal drip to someone with osteomyelitis of the bone with brain abscess and invasion of the orbit--and anything in between. I suspect that what is called chronic sinusitis is not really chronic sinusitis or is relatively minimal, and there could be some overdiagnosis." He agrees with Dr. Cantekin that the CAT scan is the best means of accurate diagnosis.

Where it concerns acute sinusitis, Dr. Ruben acknowledges that the body is well equipped to heal itself--in most cases--without treatment, but says there are times when antibiotics can be appropriate. Here again, he cautions about being certain of the diagnosis. Acute sinusitis is very severe pain in the face, facial swelling, and fever; in short, the person is very sick. He explained that it's not just the ordinary cold, and many people think they have sinusitis when it is actually rhinitis or a very low-grade sinusitis.

"Whether or not antibiotics should be given for acute sinusitis is a matter of clinical judgment," says Dr. Ruben. "For example, the patient may be debilitated, say a young child or an older person who is feverish, and have greenish yellow nasal discharge (most often, a sign of bacterial infection), then a culture may be taken to identify the specific bacteria. In this case, an antibiotic may be appropriate, he said. But if the person is otherwise healthy, and has no pain, fever or swelling, but just the greenish yellow nasal discharge, then it might be just as well to watch it."

As for the person with chronic sinusitis who goes from one antibiotic prescription to another without relief, Dr. Ruben again advises a culture to make sure what type of bacteria is present. Perhaps surgical drainage is appropriate. "If you give too many antibiotics, then you'll get antibiotic-resistant bacteria, and in the case of otitis media [childhood ear infection], this is already a huge problem." (See HealthFacts, April 1995.)

This huge problem shouldn't come as a surprise. A superinfection (or suprainfection) has long been known to be a side effect of antibiotics. This is a secondary infection that occurs on top of the initial infection for which the person was given the antibiotic. It's most likely to occur in people given a broad-spectrum antibiotic, that is, a drug capable of killing 20 different species of bacteria. (A narrow spectrum antibiotic kills only certain species, normally about three.) The killing of a broad range of "bugs" upsets the usual balance of bacteria in various parts of the body. The result is an overgrowth of organisms normally present in small enough quantities to pose no threat of disease.

The Essential Guide to Prescription Drugs 1995 offers this illustration: "When [repeated courses of antibiotics] are taken by mouth they can suppress the normally dominant forms of bacteria found in the colon and rectum, encouraging the overgrowth of yeast organisms which are capable of causing colitis. When this occurs, colitis is a superinfection."

In the 1960's and 1970's, the drug companies began to introduce a new generation of more powerful antibiotics in an attempt to overcome the emergence of drug-resistant bacteria. But the "bugs" have managed to stay ahead.

This was predicted in 1942 by Sir Alexander Fleming, the discoverer of penicillin, according to Marc Lappe, Ph.D., author of Evolutionary Medicine: Rethinking the Origins of Disease. "In fact, the first patient to be treated with a crude penicillin extract, a London bobby who developed an infection after he cut himself shaving, died in 1940 after initially responding to his treatment. This unfortunate policeman was presumably the victim of the first clinical case of penicillin-resistant Staphylococcus."

The latest generation of even more powerful antibiotics includes cefaclor (brand name: Ceclor), cefixime (Suprax), amoxicillin/clavulanate (Augmentin, Clavulin), clarithromycin (Biaxin). All are still under patent and therefore much more expensive than the older generations of antibiotics. A typical course for chronic sinusitis is now four weeks (up from 10 days) costing about $ 140. "These newer antibiotics put evolutionary pressure on the common bacteria to mutate into super bugs for which there is no effective drug," explained Dr. Cantekin, "and they impair the immune system by causing people to develop antibiotic hypersensitivity."

In the event of a life-threatening disease for which a powerful antibiotic is appropriate, the drug won't work because the person has developed a sensitivity to it. Extra care must be taken in the case of young children, explained Dr. Cantekin, because the impairment in immunity caused by antibiotic overuse in the first few years of life would probably be carried through the rest of their lives.

In Scandinavian countries where there is a concerted effort to curtail the overuse of antibiotics, Dr. Cantekin says, "Penicillin V is prescribed for only two days, and for only selected cases of acute sinusitis." This "less is better" approach was supported by a study published several months ago in JAMA (5 April 1995).

Eighty men with acute sinusitis were given either a 3-day or a 10-day course of an old "first generation" antibiotic. Additionally, all received oxymetazoline nasal spray (an active ingredient in many over-the-counter nose drops or spray products) which they were instructed to use twice daily for no more than three days. (Nasal decongestants are notorious for causing a rebound effect, that is, nasal congestion, when used for more than three days.) The group restricted to a three-day use of the antibiotic fared just as well as the group on the standard 10-day regimen. Unfortunately, this clinical trial did not include a group receiving nasal spray but no antibiotics.

Role of Sinus Surgery
The rising use of functional endoscopic sinus surgery troubles some, even those who see it as a major advance. As a minimally invasive operation which can be performed relatively quickly in an outpatient setting, it's bound to be overdone (see HealthFacts, December 1993). When antibiotics fail to cure chronic sinusitis, surgical drainage of the sinuses can be an appropriate next step, says Dr. Ruben. "Fortunately we have new surgery [functional endoscopic sinus surgery], which in the right hands can be very conservative and minimally invasive, but I emphasize that it must be done by the right surgeon, because unfortunately, it can be performed excessively, and it can cause serious problems like blindness and meningitis." Sinus surgery can also correct some anatomical abnormality, which contributes to sinusitis.

Dr. Cantekin is also concerned about unnecessary sinus operations. He likens the "explosion" of sinus surgery that has occurred over the last few years to what has happened to children with otitis media with effusion (chronic ear fluid) who go on to have ear tube placement surgery to drain the middle ear canal. "Doctors give them a drug that makes the condition chronic, and then they operate." (See HealthFacts, April 1995.)

Antibiotic Overkill
Have all the books and articles about drug-resistant bacteria made doctors more cautious about prescribing them? Not according to the most recent survey of antibiotic prescribing practices of office-based physicians in 1992 which was published early this year in JAMA (18 January 1995) by Linda F. McCraig, M.P.H., and James M. Hughes, M.D. An astounding 110 million prescriptions were written in the U.S. by office-based physicians in 1992. That's nearly one prescription for every other American, and this is not counting the antibiotics ordered in a hospital or nursing home setting. Thirteen million antibiotic prescriptions were written that year for sinusitis.

The rate of antimicrobial prescriptions written to children was even more alarming, 928 prescriptions for every 1,000 children. This 1992 survey documented major increases in the incidence of sinusitis and otitis media. McCraig and Hughes concluded that the increased use of broader-spectrum and more expensive antimicrobial drugs have implications for the health of all people because of the impact on health care costs and the potential for the emergence of antimicrobial resistance.

* Dr. Cantekin says he conducted a computerized search of the medical literature to find all clinical trials involving children with acute sinusitis. He found only one randomized controlled clinical trial which included a group of children not treated with antibiotics. The study participants were given either a nasal decongestant alone or a decongestant plus an eight- to ten-day course of antibiotics. No difference was shown in symptoms between the two groups, though the x-rays of the anti-biotic-treated children looked better.

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