“Our findings suggest that doctors should keep it simple when treating adults for acute, uncomplicated sinusitis,” says Jay F. Piccirillo, M.D., associate professor of otolaryngology and lead author of the study. Express Scripts Inc., a St. Louis-based pharmacy benefit management firm, provided the data for the study.
Acute sinusitis is an infection and inflammation of the paranasal sinuses (those above, below and on either side of the nose) of four weeks duration or less. About 35 million people in the United States are affected by sinusitis each year generating almost 3 million office visits.
In this study, researchers examined data from 29,102 adults who received initial antibiotic treatment for acute, uncomplicated sinusitis between July 1, 1996, and June 30, 1997.
The team found that 17 different antibiotics had been prescribed to sinusitis patients. These antibiotics were categorized as first-line or second-line. First-line antibiotics, such as amoxicillin, co-trimoxazole and erythromycin, generally are recommended for initial treatment of an infection. Second-line antibiotics, such as clarithromycin and amoxicillin-clavulanate, are intended for patients who are not helped by or cannot tolerate first-line drugs. First-line antibiotics typically are older and less expensive than second-line drugs. Second-line drugs also target a wider range of bacteria than first-line drugs. The study revealed that 60 percent of all patients in the database had received first-line antibiotics, while 40 percent had received second-line therapy. Primary-care physicians prescribed first-line antibiotics 60 percent of the time, while specialists prescribed second-line antibiotics 63 percent of the time.
The researchers deemed treatment to be successful if the patient did not require additional antibiotics for 28 days following initial treatment. Those patients who received first-line antibiotics had a 90.1 percent success rate, while those who received second-line drugs had a 90.8 percent success rate.
“A 0.7 percent difference between the two groups is too small to be clinically significant,” says Piccirillo, who also is director of the Clinical Outcomes Research Office in the Department of Otolaryngology. “Essentially, the two types of antibiotics were equally successful.”
But while the effectiveness of the two groups of drugs was nearly identical, their cost was strikingly different. Charges for patients who received first-line antibiotics were, on average, $68.98, while charges for those given second-line antibiotics were $135.17, a difference of $66.19.
“By showing that cost is the only difference between first- and second-line antibiotics in the treatment of acute, uncomplicated sinusitis, this study validates nationally accepted practice guidelines recommending initial use of first-line over second-line antibiotics," says Mark Frisse, M.D., chief medical officer of Express Scripts and a coauthor of the study.
Initial treatment of the disorder is further complicated by the fact that sinusitis usually begins as a viral infection. Antibiotics should be used to treat bacterial infections; indiscriminate use of antibiotics has contributed to the emergence and spread of antibiotic-resistant bacteria.
“Because of this problem,” says Piccirillo, “patients with signs and symptoms of acute, uncomplicated sinusitis should be treated only with a decongestant for the first three to five days.”
Most viral infections run their course in seven to 10 days, he says. “After about five days, a person with a viral infection should begin feeling better. If, on the other hand, their nasal discharge becomes more colored—yellow or green—and they are in more pain, then a course of antibiotics is appropriate.”
Funding for the study, along with pharmacy and medical claims data, was provided by Express Scripts Inc. Piccirillo served as a paid consultant for Express Scripts Inc.
Piccirillo JF, Mager DE, Frisse ME, Brophy RH, Goggin A. Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis. Journal of the American Medical Association, 286(15), 1849-1856, Oct. 17, 2001.
The full-time and volunteer faculty of Washington University School of Medicine are the physicians and surgeons of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient-care institutions in the nation. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.
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JAMA