Do antibiotics improve outcomes in chronic rhinosinusitis?

Journal of Family Practice, March, 2004 by S. Shevaun Duiker, Sandi Parker

* EVIDENCE-BASED ANSWER

For children, antibiotics do not appear to improve short-term (3-6 weeks) or long-term (3 months) outcomes of chronic rhinosinusitis (strength of recommendation [SOR]: A, randomized controlled trials). No adequate placebo-controlled trials have been performed in adults. Two consensus statements report that 10 to 21 days of antibiotics active against organisms producing beta-lactamase might be beneficial in some cases (SOR: C).

* EVIDENCE SUMMARY

The American Academy of Otolargynology-Head and Neck Surgery defines chronic rhinosinusitis as the persistence of 2 major or 1 major and 2 minor criteria lasting at least 12 weeks (Table). (1) The other categories of rhinosinusitis are acute (symptoms lasting <3 weeks) and subacute (symptoms lasting 3-12 weeks).

Two placebo-controlled trials have evaluated antibiotic treatment of chronic rhinosinusitis in children. In 1 study, 141 children with chronic rhinosinusitis were randomly assigned to 1 of 4 treatment arms: saline nose drops; xylometazoline (Otrivin) drops with oral amoxicillin 3 times daily; surgical drainage; or surgical drainage, amoxicillin 3 times daily and xylometazoline drops. (2) Outcomes were resolution of purulent rhinitis, no purulent drainage on exam, and no abnormalities of maxillary sinus on x-ray. The absence of all 3 findings constituted cure. At 6 weeks there was a non-statistically significant higher resolution in the fourth group, but by 26 weeks the groups were indistinguishable. At 6 weeks, 53%, 50%, 55%, and 79% of each group, respectively, were cured. These results increased to 69%, 74%, 69%, and 64% at 26 weeks.

Another study randomized 79 children with chronic sinusitis to treatment with cefaclor vs placebo following antral washout. (3) Measured outcomes were similar to those in the prior study. At 6 weeks, 12.3% more patients in the antibiotic group achieved cure than the placebo group (64.8% vs 52.5%), but this difference was not statistically significant (P = .28). At 12 weeks, no differences in improvement were seen between the 2 groups (89% vs 89.5%)

No studies (since 1966) have evaluated antibiotic use compared with placebo in adults. We did not review the numerous studies comparing different antibiotics without placebo.

* RECOMMENDATIONS FROM OTHERS

The American Academy of Otolaryngology--Head and Neck Surgery, in conjunction with the American Academy of Rhinology and the American Academy of Otolaryngic Allergy, state that the use of antibiotics active against beta-lactamase producing organisms might be beneficial in some cases. (3) A consensus statement from a panel convened in Belgium in 1996 stated antibiotics should be given for 5 to 7 days with repeat treatments if the child does not respond initially. (5)

* CLINICAL COMMENTARY

Antibiotics provide only short-term relief, not long-term answers

For chronic sinusitis, I start by emphasizing nonantibiotic treatments, such as decongestants, nasal steroids, antihistamines, smoking cessation, and avoidance of passive smoke, allergens, and other irritants. With education and experience, patients realize that antibiotics provide only short-term relief, not long-term answers. Having learned this, patients can better participate in antibiotic treatment decisions. Most are able to weigh the short-term, symptomatic benefits against potential medication side effects and the cost. I believe that 2 or 3 courses of antibiotics per year are not excessive, but I try not to exceed that limit.

Finally, I don't always choose a beta-lactamase-resistant antibiotic. Given that antibiotics do not alter the long-term prognosis, I worry less about resistance and more about minimizing cost and side-effect potential. Therefore, I occasionally treat with amoxicillin or Pen Vee K. Patients seem to appreciate my flexibility and collaborative approach to decision-making.

William A. Hensel, MD, Moses Cone Family Residency Program, Greensboro, NC

TABLE 2

Diagnostic criteria for rhinosinusitis

Major criteria

Facial pain/pressure *

Facial congestion/fullness

Nasal obstruction/blockage

Nasal discharge/purulence/discolored drainage

Hyposmia/anosmia

Purulence in nasal cavity on examination

Fever (acute only) *

Minor criteria

Headache

Fever (all nonacute)

Halitosis

Fatigue

Dental pain

Cough

Ear pain/pressure/fullness

* Symptom alone does not constitute a major sign in the absence of another major nasal symptom. Adapted from Lanza DC, 1997.

REFERENCES

(1.) Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997; 117(3 Pt 2): S1-S7.

(2.) 0tten FW, Grote JJ. Treatment of chronic maxillary sinusitis in children. Int J Pediatr Otorhinolaryngo1 1988; 15:269-278.

(3.) 0tten HW, Antvelink JB, Ruyter de Wildt H, Rietema SJ, Siemelink RJ, Hordijk GJ. Is antibiotic treatment of chronic sinusitis effective in children? Clin Otolaryngo 1994; 19:215-217.

(4.) Benninger MS, Anon J, Mabry RL. The medical management of rhinosinusitis. Otolaryngol Head Neck Surg 1997; 117(3 Pt 2): S41-S49.

(5.) Clement PA, Bluestone CD, Gordts F, et al. Management of rhinosinusitis in children: consensus meeting, Brussels, Belgium, September 13, 1996. Arch Otolaryngol Head Neck Surg 1998; 124:31-34.