Vanguard Neurologist

From MedScape

For treatment of acute maxillary sinusitis, the potential, but small, benefits of antibiotics should be weighed against the risk for adverse effects and development of resistance, according to a Cochrane review of 57 studies reported in the April 16 issue of the Cochrane Database Systematic Review. Although this review showed a small treatment effect in primary care patients with uncomplicated acute sinusitis who had symptoms for more than 7 days, 80% of those who were untreated improved within 2 weeks.

“Expert opinions vary on the appropriate role of antibiotics for sinusitis, one of the most commonly diagnosed conditions among adults in ambulatory care,” write Anneli Ahovuo-Saloranta, DDS, from the Finnish Office for Health Technology Assessment/FinOHTA, National Research and Development Centre for Welfare & Health/STAKES, in Tampere, Finland, and colleagues.

“Treatment recommendations for acute sinusitis are divided and range from only treating patients with severe or persistent moderate symptoms and specific bacterial sinusitis findings with narrow spectrum antibiotics; to treating all patients with acute bacterial sinusitis with broad spectrum antibiotics. The purpose of antibiotics is to decrease symptoms and restore the normal function of the sinuses, in order to prevent complications and the development of chronic sinusitis.”

The goal of this review was to assess the efficacy of antibiotics in treating acute sinusitis, and if efficacy were shown, to determine which antibiotic classes are the most effective. The reviewers searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, 2007, Issue 3), MEDLINE (1950 to May 2007), and EMBASE (1974 to June 2007) for randomized controlled trials comparing antibiotics with placebo or antibiotics from different classes for acute maxillary sinusitis in adults.

Trials with clinically diagnosed acute sinusitis were included, regardless of whether diagnosis was confirmed by radiography or bacterial culture.

Two or more review authors independently screened the search results, extracted data, and determined the quality of the included trials. To assess whether the administered treatment was a success or a failure, risk ratios (RR) were calculated for differences between the intervention and control groups. For meta-analysis of placebo-controlled trials, data were combined across antibiotic classes. The main endpoints were the clinical failure rates at 7 to 15 days and at 16 to 60 days follow-up.

Of 57 studies included in the review, 6 were placebo-controlled trials, and 51 were studies comparing different antibiotics classes. There were 5 studies, enrolling a total of 631 participants, that provided data allowing comparison of antibiotics with placebo in terms of clinical failure, defined as a lack of cure or improvement at 7 to 15 days follow-up.

In these studies, there was a slight statistical difference favoring antibiotics over placebo, with a pooled RR of 0.66 (95% confidence interval [CI], 0.44 – 0.98). Clinically, however, this result was of equivocal significance because cure or improvement rate was high in both the placebo group (80%) and in the antibiotic group (90%).

There were 6 studies in which clinical failure was defined as a lack of total cure. In these, antibiotics were significantly better than placebo, with a pooled RR at 7 to 15 days follow-up of 0.74 (95% CI, 0.65 – 0.84). None of the antibiotic preparations was superior to any of the others.

“Antibiotics have a small treatment effect in patients with uncomplicated acute sinusitis in a primary care setting with symptoms for more than seven days,” the review authors conclude.

“However, 80% of participants treated without antibiotics improve within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population level.”