Doctors should not be prescribing antibiotics to adults for the common rhinosinusitis infection, even if patients report symptoms lasting longer than 7-10 days. These are the conclusions of authors of an Article in this week's edition of The Lancet.
Upper respiratory tract infections are the third most common reason for a doctor's consultation (USA) and around a third of these infections are diagnosed as acute rhinosinusitis. However, because it is very difficult to distinguish the bacterial and viral forms of the illness, doctors continue to overprescribe antibiotics. In the USA 80% of patients with a rhinosinusitis diagnosis are prescribed an antibiotic, while in Europe the proportion is 72-92%. Increased rates of antibiotic resistance are seen in countries where antibiotic use is highest and antimicrobial resistance has led to higher rates of disease and death throughout the world.
Dr Jim Young, Basel Institute for Clinical Epidemiology, University Hospital Basel, Switzerland, and colleagues, did a meta-analysis (a pooling of previous studies) using data from 2547 adults from nine trials. The patients, who had rhinosinusitis-like complaints, were randomly assigned to treatment with an antibiotic or a placebo. The authors investigated the overall effect of antibiotic treatment and prognostic value of common signs and symptoms, by looking at the number needed to treat (NNT) with antibiotics in order to cure one patient.
They found that 15 patients with rhinosinusitis had to be given antibiotics before an additional patient was cured; for patients with a phlegm-like discharge from the throat, this NNT reduced to 8. Patients who were older, reported symptoms for longer, or reported more severe symptoms also took longer to cure but were no more likely to benefit from antibiotics than other patients.
The authors say: "The implication for primary care is that antibiotics offer little benefit for patients with acute rhinosinusitis-like complaints. Common clinical signs and symptoms cannot identify a subgroup for which treatment is clearly justified, given the cost, adverse events, and bacterial resistance associated with antibiotic use. Antibiotics are not justified even if a patient reports symptoms for longer than 7-10 days."
They conclude: "Although our results do not apply to children or patients with a suppressed immune system, they should reassure physicians that only watchful waiting and symptomatic relief are warranted for almost all adult patients with acute rhinosinusitis-like complaints."
In an accompanying Comment, Dr Morten Lindbaek, Antibiotic Centre for Primary Care, University of Oslo, Norway, and Dr Christopher Butler, Centre for Health Sciences Research, School of Medicine, Cardiff University, UK, say: "Young and colleagues have shown that if any subgroups of patients with mild sinusitis respond substantially to antibiotic treatment, these subgroups are not easy to identify...Perhaps the time has come for researchers to agree on common definitions, a minimum dataset, at least one standard outcome, and best mode of administration for treatment trials in common infections? Such consensus could pave the way for major changes in treatment."
Dr Jim Young, Basel Institute for Clinical Epidemiology, University Hospital Basel, Switzerland T) +41 61 265 3100 E) jyoung@uhbs.ch
Dr Morten Lindbaek, Antibiotic Centre for Primary Care, University of Oslo, Norway T) +47 92454850 E) morten.lindbak@medisin.uio.no
PDF OF ARTICLE: http://multimedia.thelancet.com/pdf/press/Rhinosinusitis.pdf
Journal
The Lancet