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Don't Prescribe Antibiotics for Adult Sinus Woes

THURSDAY March 13, 2008 -- It's extremely difficult for doctors to tell the difference between sinus infections that can be cured by antibiotics and those that can't, a new review finds.

Given the growing problem of antibiotic resistance, the study authors urge that physicians give up using antibiotics altogether for adult patients with rhinosinusitis -- even when symptoms persist beyond a week.

"Antibiotics offer little benefit for patients with acute rhinosinusitis-like complaints," wrote the research team led by Dr. Jim Young of University Hospital Basel, Switzerland. "Antibiotics are not justified even if a patient reports symptoms for longer than 7-10 days," they added in the March 15 issue of The Lancet.

The European group noted that upper respiratory tract infections are responsible for a full third of doctor's appointments in the United States, and a third of those visits end in a diagnosis of rhinosinusitis. Currently, about 80 percent of patients receive a prescription for an antibiotic.

Antibiotics are only useful against bacterial disease -- they do not fight viral infections. But how good are doctors at distinguishing between the two in the typical clinical setting?

To find out, Young's group looked at data from nine trials with a total of more than 2,500 adult patients with rhinosinusitis. Doctors in the trials used a patient's medical history or symptoms -- for example, facial pain, pus-filled nasal discharge, or a prior cold -- that have been thought helpful in distinguishing a bacterial infection from a viral one.

Unfortunately, even these symptoms failed to help doctors determine whether antibiotics were appropriate. In fact, the analysis found that 15 patients with rhinosinusitis-like complaints had to be given antibiotics before one additional patient benefited from treatment, meaning that the other 14 were getting the drugs for no real purpose, the authors wrote. The result didn't change, regardless of patient age or duration or severity of symptoms.

The findings only apply to adult patients because children were not included in the study, the researchers stressed.

However, one otolaryngologist said the study goes too far in banning antibiotics for adult cases.

"This study should not convey the message that antibiotics are not indicated for all patients with sinusitis," Dr. Jordan S. Josephson, of Lenox Hill Hospital in New York City, said in a statement. He believes that while the drugs are certainly ineffective against viral sinusitis, they can offer patients with acute bacterial infections "significant symptom relief and improvement."

Josephson notes the study does not address "the 30-plus million Americans that suffer from chronic sinusitis." He said the evidence is clear that many patients with these longer-term sinus problems do benefit from antibiotic therapy.

However, the new findings mirror those of a study published last March in the Archives of Otolaryngology Head and Neck Surgery. That study found that U.S. doctors are consistently overprescribing antibiotics for sinus infections.

But even the physician who led that research doesn't see how the problem can be eliminated.

That's because when it comes to treatments for sinus trouble, antibiotics are the best of a bad lot, said Dr. Donald A. Leopold, chairman of the department of otolaryngology at the University of Nebraska Medical Center.

"We as physicians don't have very good medications for chronic rhinosinusitis," he said. "The only other drugs in contention are topical steroids, and they are not great. As a group, I suggest we are frustrated at not having good drugs. It would be great if we had better medications for this chronic inflammation."

Another factor is what patients demand, Leopold said. "Many patients call up and ask for specific antibiotics," he said. "The patients know these names. They have been marketed to them, so they know the drugs are available. And antibiotics do give some relief."

According to the Archives of Otolaryngology Head and Neck Surgery report, two national studies showed that Americans made more than 17 million visits to health-care facilities for sinus infections between 1999 and 2002. At least one antibiotic was prescribed in nearly 83 percent of cases of acute rhinosinusitis and in nearly 70 percent of cases of the chronic, longer-running version of the condition, in which symptoms persist for at least 12 weeks.

Doctors understand that overprescribing antibiotics can lead to a dangerous microbial resistance to the drugs. But it's hard to preach that wisdom to someone with a drippy, hurting sinus who wants immediate relief, Leopold acknowledged. Because more effective drugs are lacking, "patients are desperate, physicians are desperate, and it is not a happy situation," he said.

Consider the case of the working physician called on to treat such a patient, said Dr. Neil L. Kao, vice chairman of the rhinitis/sinusitis committee of the American College of Allergy, Asthma and Immunology. He happens to be just such a working physician, in private practice in Greenville, S.C.

There are ways to determine whether a sinus infection is bacterial, Kao said. One is to do endoscopy, running a tube into the nose to obtain a sample of mucus from the sinus. Another is nasal cytology, examining a swab from the lining of the nose. A third is to take an X-ray.

"The problem with all of these is that they are expensive and time-consuming," Kao said. "The differences between symptoms caused by an allergy, bacterial infection, viral infection and a common cold are few. For us, even specialist doctors, when you see someone with acute nasal symptoms, it is hard to tell the cause. And the truth is that most of the people diagnosed with sinusitis go to primary-care doctors."

Public awareness about antibiotic resistance is increasing, but most people suffering from cough, drip, lack of sleep and other sinus symptoms are likely to come in demanding an antibiotic, Kao said.

And so the physician often makes the practical choice of giving what the patient wants, with a chance of relief, over the more abstract issue of antibiotic resistance, he said.

Posted: March 2008


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