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Evid Based Nurs 9:43 doi:10.1136/ebn.9.2.43
  • Treatment

Review: antibiotics are more effective than placebo for acute bacterial rhinosinusitis


 
 Q What are the relative efficacies of various antibiotics for treatment of acute bacterial rhinosinusitis? Does duration of treatment affect efficacy?

METHODS

GraphicData sources:

Medline (1997 to September 2004), reference lists of relevant reviews, and technical experts.

GraphicStudy selection and assessment:

published English language randomised controlled trials (RCTs) that included ⩾10 patients per group and compared antibiotics with placebo or other antibiotics in patients of any age with acute (<30 d) uncomplicated bacterial sinusitis or acute exacerbation of chronic sinusitis. Studies of patients with chronic sinusitis only or other respiratory infections were excluded. 2 reviewers independently assessed studies for methodological quality using a 3 category score based on level of bias.

GraphicOutcomes:

treatment failure (lack of improvement or worsening of signs and symptoms by the end of treatment) and recurrence (persistent or relapsed disease ⩾1 wk after the end of treatment).

MAIN RESULTS

39 RCTs (15 739 patients) met the selection criteria. All RCTs were funded by, or had authors affiliated with, pharmaceutical companies. Most RCTs had moderate or low methodological quality. Classes of antibiotics studied were penicillins, cephalosporins, macrolides, azalides, ketolides, quinolones, carbapenems, and tetracyclines. Duration of treatment ranged from 3 days to 4 weeks. Meta-analyses used per protocol data and a random effects model. Treatment failure rate was lower in the antibiotic group than in the placebo group (table), although 65% of patients in the placebo group improved or were cured. Cephalosporins had a higher rate of treatment failure, but not recurrence, than amoxicillin/clavulanate (table). Quinolones did not differ from amoxicillin/clavulanate (4 trials, n = 1595), cephalosporins (5 trials, n = 3033), or macrolides (4 trials, n = 1516) for treatment failure or recurrence; macrolides/azalides/ketolides did not differ from amoxicillin/clavulanate (5 trials, n = 2109) or cephalosporins (3 trials, n = 926) for treatment failure or recurrence. Of 8 individual trials that compared different treatment durations with various antibiotics, none found a difference in efficacy between short and long durations; meta-analysis was not done.

CONCLUSIONS

Antibiotics are more effective than placebo for acute bacterial rhinosinusitis. Amoxicillin/clavulanate is more effective than cephalosporins in the short term. Results of individual trials showed no differences between short and long treatment durations.

Commentary

  1. Claudia Mariano, RN(EC), MSc
  1. East End Community Health Centre, Toronto, Ontario, Canada

      Many studies have evaluated the effect of various antibiotics on acute bacterial rhinosinusitis (or simply sinusitis). With so many treatment options, it is difficult to know which antibiotic is best, or if antibiotics are required at all. The review by Ip et al is especially important in light of current issues with antibiotic resistance and provider prescribing patterns.

      Amoxicillin/clavulanate was found to be more effective than some newer, more expensive, broad spectrum antibiotics. The review was limited to studies published since 1997 and thus did not evaluate older antibiotics, such as amoxicillin and trimethoprim-sulfamethoxazole, although these were included in a previous version of this review.1 This emphasis on newer drugs is contrary to some current clinical practice guidelines, which list amoxicillin as the first choice for acute bacterial rhinosinusitis.2 Other guidelines recommend respiratory fluoroquinolones (or high dose amoxicillin/clavulanate) as effective first line treatment but acknowledge that this approach may result in high rates of resistance.3

      Diagnosis of acute bacterial rhinosinusitis appeared to be accurate and consistent, as 33 of 39 trials in the review used either radiography or computed tomography of the sinuses to confirm eligibility. The use of clinical symptoms, such as purulent nasal discharge/congestion, facial pain/tenderness, headache, toothache, periorbital oedema, halitosis, fever, and cough, concurs with current guidelines on diagnosing acute rhinosinusitis.2,3 Although antibiotics were found to be superior to placebo, symptoms improved in 65% of patients taking placebo, suggesting that symptomatic treatment alone may be a prudent option.

      The decision as to when, and if, antibiotic treatment is required is within the scope of the healthcare provider. Nurses in primary care have an opportunity to use the results of the review by Ip et al to reduce the financial burdens associated with antibiotic use by reassuring patients that symptom relief or treatment with older, less expensive antibiotics may be all that is warranted.

      References

      Antibiotics v placebo or other antibiotics for acute bacterial rhinosinusitis*

      
 
 Q What are the relative efficacies of various antibiotics for treatment of acute bacterial rhinosinusitis? Does duration of treatment affect efficacy?

      Footnotes

      • For correspondence: Dr S Ip, Tufts-New England Medical Center, Boston, MA, USA. sip{at}tufts-nemc.org

      • Source of funding: US Agency for Healthcare Research and Quality.

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