Acute Bacterial Sinusitis: Treatments Assessed

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Inexpensive antibiotics such as amoxicillin are just as effective in treating acute bacterial sinusitis as the newer, expensive antibiotics. In most cases, however, symptoms of acute bacterial sinusitis will go away without any treatment. These are some of the conclusions from a report issued early this year from the U.S. Agency for Health Care Policy and Research. It is the latest in a series intended to search the published medical literature to find evidence to answer basic questions about a common treatment: Does it work? If so, for whom?

Sinusitis is one of the most common infections in the U.S., accounting for over $200 million spent on prescription drugs in 1992 alone and another $2 billion for over-the-counter drugs. The condition, which in most cases involves inflammation of the sinuses and nasal passages, has a variety of causes. According to the report, this includes infectious agents (bacteria, viruses, and fungi), allergic conditions (allergic rhinitis), anatomic abnormalities, systemic disease (endocrine, metabolic, genetic), trauma, and noxious chemicals. If sinusitis is not caused by bacteria, antibiotics are useless.

All Studies Assessed
The report was compiled by the New England Medical Center Evidence-based Practice Center, under contract with the Agency for Health Care Policy and Research. A panel of experts provided recommendations to physicians after a thorough assessment of all relevant published studies. Where research is lacking, the gaps were identified; for example, there has been little research on children, despite their high incidence of acute sinusitis.

"The overall methodological quality and reporting of both diagnostic and treatment studies on this topic are poor. Few studies were conducted in North America," according to the panel members. Working with imperfect studies they concluded:

More patients were cured and cured earlier when treated with antibiotics rather than placebo [dummy pill].
About two-thirds of the patients receiving placebo [i.e, no treatment] recovered without antibiotics.
Serious complications of rhinosinusitis, such as meningitis, brain abscess, and periorbital cellulitis are rare, and none were reported in the clinical trials examined for this study.
Most clinical trials have only short-term follow-up and report no data on relapse.
Amoxicillin or folate inhibitors [older antimicrobials, e.g., sulfonamides and trimethoprim] are as efficacious as the newer and more expensive antibiotics. The current evidence does not justify the use of the newer antibiotics for treating uncomplicated, community-acquired acute bacterial rhinosinusitis.
The older antibiotic, amoxicillin, can be purchased generically. A ten-day supply is about $7, whereas a similar amount of a newer antibiotic in the cephalosporin class (e.g., Omnicef, Cefzil) is about $70. Do side effects differ? The report says no. About 4% of people taking amoxicillin in clinical trials withdrew because of side effects. This is about the same rate as those who withdrew because of side effects caused by the newer class of antibiotics.

Doctors also prescribe decongestants, antihistamines, steroids, and drainage/irritation for acute bacterial rhinosinusitis. Unfortunately, the panel could not answer the question of how they compare in efficacy to antibiotics or to each other. Although ten randomized controlled trials assessed one or more of these treatments, no conclusion could be drawn because of inconsistencies in the way the studies were conducted.

For More Information:
For a summary of Evidence Report Number 9 Diagnosis and Treatment of Acute Bacterial Rhinosinusitis (AHCPR99-EO15), call 1(800)358-9295 or visit the Agency for Health Care Policy and Research Web site (http://www.ahcpr.gov/clinic/sinussum.htm).

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