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Acute Maxillary Sinusitis — Is Treatment Effective?
Abstract & Commentary
By Robert Muder, MD, Hospital Epidemiologist, Pittsburgh VA Medical Center,Section Editor, Hospital Epidemiology, is Associate Editor for Infectious Disease Alert.
Dr. Muder does research for Aventis and Pharmacia.
Synopsis: In a randomized, controlled trial in a primary care setting, neither oral amoxicillin nor topical corticosteroids, singly or in combination, hastened resolution of acute maxillary sinusitis.
Source: Williamson IG, et al. Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: A randomized controlled trial. JAMA. 2007;298:2487-2496.
Acute sinusitis is a common presenting complaint in primary care; most cases are treated with oral antibiotics despite controversy as to whether such treatment is effective. Williamson and colleagues conducted a randomized, controlled trial of treatment of acute maxillary sinusitis. They enrolled 240 adult patients from primary care practices in Great Britain. Patients had acute (< 28 days duration) sinusitis based on clinical criteria that have been shown to correlate well with the results of antral puncture.1 Patients were required to have at least 2 of the following: purulent nasal discharge with unilateral predominance, local pain with unilateral predominance, purulent nasal discharge, or pus on inspection of the nasal cavities. Patients were excluded if they had serious underlying illness or 2 or more episodes of sinusitis within the preceding year. Eligible patients were randomized to 4 groups: topical budesonide 200 ug daily for 10 days, oral amoxicillin 500 mg three times daily for 7 days, budesonide + amoxicillin, or placebo.
At the end of 10 days, 30% of patients were symptomatic, and by day 14, 80% of patients reported complete resolution. There were no significant differences for any treatment compared with placebo. The patients were followed out to 6 weeks, and none suffered any adverse consequences. Williamson et al concluded that neither topical steroids nor amoxicillin, alone or in combination, were effective.
Treating acute sinusitis with oral antibiotics is a fairly standard practice, despite lack of convincing evidence of its efficacy. Unnecessary antibiotic use in ambulatory care is a significant factor in the emergence of antibiotic resistance in respiratory pathogens such as Streptococcus pneumoniae.
The study by Williamson et al provides good evidence that antibiotics and topical corticosteroids can be withheld in otherwise healthy patients with acute sinusitis. This study has a number of strengths, the most significant of which is that it was conducted in a primary care setting and thus reflects the patient population likely to be seen by the generalist. The use of a clinical definition of sinusitis, while not validated in the primary care setting, is practical and relevant since antral puncture with culture and radiography are typically used in primary care. It's notable that none of the patients treated with placebo suffered any significant adverse consequences. It should be noted, however, that over two-thirds of the patients had only 2 symptoms or signs, the minimum number required for enrollment, and most were afebrile. In addition, patients with significant underlying illness or multiple recurrences were excluded. Therefore, expectant treatment may not be appropriate for patients with severe symptoms, high fever, multiple recurrences, or serious comorbidities.
Although this study provides good evidence that symptomatic treatment alone is appropriate for uncomplicated sinusitis, patients will continue to request antibiotic therapy for this condition. Although appropriate patient education takes considerably more effort than reaching for the prescription pad, it is the preferable course.