Antibiotics for acute maxillary sinusitis

Safety of a New Sinus Irrigation Device in Rhinosinusitis: A Pilot Study

BACKGROUND

Puncture and lavage of the paranasal sinuses, previously the primary treatment for unresponsive acute bacterial rhinosinusitis before surgery, has been abandoned due to procedural discomfort and advancements in antibiotic efficacy and endoscopic surgery. The rise in antibiotic-resistant bacteria has renewed the interest in minimally invasive sinus lavage to both avoid aggressive surgical interventions and identify appropriate antibiotic therapy. In this article, we describe the safety and feasibility of a new device in human patients and evaluate its efficacy as a treatment before the traditional sinus surgery in acute rhinosinusitis.

METHODS

The device with its seeker-shaped guiding tube and rotating wire can enter the sinus cavity through the natural ostium, pulverize the inspissated mucus, and enable lavage and culture sampling without the need for sinus puncturing. It was tested in 6 patients with chronic sinusitis under general anesthesia during endoscopic sinus surgery and in additional 10 patients with maxillary acute bacterial rhinosinusitis in outpatient settings under local anesthesia.

RESULTS

The device enabled rapid, efficient, and atraumatic insertion of the wire into the occluded sinuses. The rotating wire permitted pulverization of the thick mucus, which enabled irrigation without mucosal damage or adverse events. Overall, 9 of 10 patients with acute bacterial rhinosinusitis demonstrated remarkable improvements and were discharged the following day with no acute symptoms. The visual analog scale score for pain dropped from 8.9 to 0.4. The remaining one patient underwent endoscopic sinus surgery subsequently. None of the patients treated during endoscopic sinus surgery developed any adverse events.

Antibiotics versus placebo for acute bacterial conjunctivitis

BACKGROUND

Acute bacterial conjunctivitis is an infection of the conjunctiva and is one of the most common ocular disorders in primary care. Antibiotics are generally prescribed on the basis that they may speed recovery, reduce persistence, and prevent keratitis. However, many cases of acute bacterial conjunctivitis are self-limited, resolving without antibiotic therapy. This Cochrane Review was first published in The Cochrane Library in 1999, then updated in 2006, 2012, and 2022.

OBJECTIVES

To assess the benefits and side effects of antibiotic therapy in the management of acute bacterial conjunctivitis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2022, Issue 5), MEDLINE (January 1950 to May 2022), Embase (January 1980 to May 2022), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.

CLINICALTRIALS

gov), and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases in May 2022.   SELECTION CRITERIA: We included randomized controlled trials (RCTs) in which any form of antibiotic treatment, with or without steroid, had been compared with placebo/vehicle in the management of acute bacterial conjunctivitis. This included topical and systemic antibiotic treatments.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the titles and abstracts of identified studies. We assessed the full text of all potentially relevant studies and determined the included RCTs, which were further assessed for risk of bias using Cochrane methodology. We performed data extraction in a standardized manner and conducted random-effects meta-analyses using RevMan Web.

MAIN RESULTS

We included 21 eligible RCTs, 10 of which were newly identified in this update. A total of 8805 participants were randomized. All treatments were topical in the form of drops or ointment. The trials were heterogeneous in terms of their eligibility criteria, the nature of the intervention (antibiotic drug class, which included fluoroquinolones [FQs] and non-FQs; dosage frequency; duration of treatment), the outcomes assessed and the time points of assessment. We judged one trial to be of high risk of bias, four as low risk of bias, and the others as raising some concerns. Based on intention-to-treat (ITT) population, antibiotics likely improved clinical cure (resolution of clinical symptoms or signs) by 26% (RR 1.26, 95% CI 1.09 to 1.46; 5 trials, 1474 participants; moderate certainty) as compared with placebo. Subgroup analysis showed no differences by antibiotic class (P = 0.67) or treatment duration (P = 0.60). In the placebo group, 55.5% (408/735) of participants had spontaneous clinical resolution by days 4 to 9 versus 68.2% (504/739) of participants treated with an antibiotic. Based on modified ITT population, in which participants were analyzed after randomization on the basis of positive microbiological culture, antibiotics likely increased microbiological cure (RR 1.53, 95% CI 1.34 to 1.74; 10 trials, 2827 participants) compared with placebo at the end of therapy; there were no subgroup differences by drug class (P = 0.60). No study evaluated the cost-effectiveness of antibiotic treatment. Patients receiving antibiotics had a lower risk of treatment incompletion than those in the placebo group (RR 0.64, 95% CI 0.52 to 0.78; 13 trials, 5573 participants; moderate certainty) and were 27% less likely to have persistent clinical infection (RR 0.73, 95% CI 0.65 to 0.81; 19 trials, 5280 participants; moderate certainty). There was no evidence of serious systemic side effects reported in either the antibiotic or placebo group (very low certainty). When compared with placebo, FQs (RR 0.70, 95% CI 0.54 to 0.90) but not non-FQs (RR 4.05, 95% CI 1.36 to 12.00) may result in fewer participants with ocular side effects. However, the estimated effects were of very low certainty.

AUTHORS' CONCLUSIONS

The findings of this update suggest that the use of topical antibiotics is associated with a modestly improved chance of resolution in comparison to the use of placebo. Since no evidence of serious side effects was reported, use of antibiotics may therefore be considered to achieve better clinical and microbiologic efficacy than placebo. Increasing the proportion of participants with clinical cure or increasing the speed of recovery or both are important for individual return to work or school, allowing people to regain quality of life. Future studies may examine antiseptic treatments with topical antibiotics for reasons of cost and growing antibiotic resistance.

Efficacy and safety of different therapies of non-steroidal anti-inflammatory drugs against antibiotic monotherapy in the treatment of uncomplicated lower urinary tract infection: A systematic review

This systematic review aimed to evaluate the efficacy of different non-steroidal anti-inflammatory drugs therapy (monotherapy or combined with antibiotics) against antibiotics monotherapy to understand the possible role of non-steroidal anti-inflammatory drugs in managing uncomplicated urinary tract infections and reduce overall antibiotic prescription. We searched four databases: PubMed, EMBASE, Scopus, and Cochrane CENTRAL. We included randomized controlled trials, which had included non-pregnant females above 18 years, published from 2010 to 2020 AD in the English language. We assessed risk of bias (ROB) using COCHRANE ROB version 2.0. We synthesized the conclusion from low ROB studies. Among five included studies, four studies compared non-steroidal anti-inflammatory drugs monotherapy against antibiotics monotherapy, and one study compared non-steroidal anti-inflammatory drugs + antibiotic therapy against antibiotic monotherapy. All studies with low ROB showed significantly higher events of symptom resolution by day 7 with antibiotic monotherapy compared to non-steroidal anti-inflammatory drugs monotherapy. Overall, adverse events were not significantly different in two of three low risk of bias studies; however, one study reported significantly higher adverse effects with non-steroidal anti-inflammatory drugs. Non-urinary tract infection–related adverse events were more common than urinary tract infections–related adverse events in both non-steroidal anti-inflammatory drugs and antibiotic groups. Urinary tract infection–related adverse events were higher in the non-steroidal anti-inflammatory drugs group compared to antibiotics. For every 20–60 participants treated, one would develop pyelonephritis additionally in non-steroidal anti-inflammatory drugs compared to antibiotics. Antibiotics were superior to non-steroidal anti-inflammatory drugs for treating uncomplicated lower urinary tract infections. However, further studies regarding the characteristics of patients likely to develop pyelonephritis on non-steroidal anti-inflammatory drugs monotherapy, and the effectiveness and safety of a combination of non-steroidal anti-inflammatory drugs and antibiotics therapy are essential to reduce the burden of antibiotics and their associated problems.

[Systemic and local antibiotic therapy for acute sinusitis]

The purpose of the study was to summarize data on modern antibiotic therapy for acute sinusitis, the role and place of topical antibacterial drugs, in particular Fluimucil-Antibiotic, in modern treatment strategies for this disease.

METHODS

Search in the PUBMED electronic database (articles and related abstracts) for the keywords «acute sinusitis", «antibiotics», «thiamphenicol glycinate acetylcysteine» «biofilm», «respiratory tract infection», «N-acetylcysteine».

RESULTS

The published research results indicate the high antibacterial activity of the Fluimucil-Antibiotic, in particular, for the topical drug use in the form of inhalations, applications, irrigation, and instillations. The published research results indicate a wide spectrum of antimicrobial action of Fluimucil-Antibiotic, its ability to destroy biofilms and prevent their formation, good pharmacokinetics, safety, which makes it possible to consider it as a potential treatment option for acute sinusitis in everyday practice.

Procalcitonin as a Biomarker in Rhinosinusitis: A Systematic Review

OBJECTIVES

(1) To describe the existing literature on procalcitonin (PCT) as a biomarker in patients with acute rhinosinusitis (ARS), (2) to analyze outcomes in ARS patients who were treated with PCT-guided therapy versus traditional management, and (3) to compare PCT to other biomarkers used in diagnosis of bacterial ARS. Data Sources: PubMed and Embase. Review Methods: A systematic search in the PubMed and Embase databases was performed to identify studies related to PCT as a biomarker in ARS. After critical appraisal of validity by 2 authors, 6 studies with a total of 313 patients were selected for data extraction and analysis. We identified 2 randomized control trials (RCTs) of PCT-based guidelines for antibiotic management of ARS in outpatient settings and 4 observational studies that compared PCT to other biomarkers in patients with ARS.

RESULTS

The 2 RCTs demonstrated a reduction (41.6% in 1 study and 71% in the other) in antibiotic prescription rate in the PCT-guided group versus the control group with no change in the number of days with impaired activity due to illness (9.0 vs 9.0 days [ P = .96]; 8.1 vs 8.2 days [95% confidence interval -0.7 to 0.7]), number of days of work missed, and percentage of patients with persistent symptoms at 28 days. In the observational cohort studies, PCT did not consistently correlate with C-reactive protein, body temperature, and/or white blood cell counts.

CONCLUSIONS

The limited existing literature on the role of PCT in diagnosis, management, and prediction of clinical outcomes in ARS suggests that PCT-based guidelines for antibiotic prescription are a safe and effective method of minimizing unnecessary antibiotic use.

Antibiotics for acute rhinosinusitis in adults

BACKGROUND

Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear.We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging.

OBJECTIVES

To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings.

SEARCH METHODS

We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines.

SELECTION CRITERIA

Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis-like signs or symptoms or sinusitis confirmed by imaging.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required.

MAIN RESULTS

We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I² = 0%; 8 trials; high-quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I² = 0%; 3 trials; moderate-quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate-quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I² = 0%; 3 trials; high-quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I² = 16%; 10 trials; high-quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I² = 21%; 12 trials; high-quality evidence). A disease-related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group).

AUTHORS' CONCLUSIONS

The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high-quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate-quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials.

Overuse of diagnostic tools and medications in acute rhinosinusitis in Spain: a population-based study (the PROSINUS study)

OBJECTIVES

Acute rhinosinusitis (ARS) has a high incidence. Diagnosis is clinical, and evolution is mostly self-limited. The aim of this study was to describe the sociodemographic characteristics and use of diagnostic tools and medications in patients with ARS.

DESIGN

This is a prospective observational study in real-life clinical practice.

SETTING

Patients with clinical diagnosis of ARS (n=2610) were included from ear, nose and throat clinics in Spain. A second visit at resolution was done.

PARTICIPANTS

Patients were classified according to the duration of symptoms: viral ARS (≤10 days), postviral ARS (>10 days, ≤12 weeks) and chronic rhinosinusitis (>12 weeks).

MAIN OUTCOME MEASURES

Sociodemographic characteristics, symptoms, disease severity, quality of life (Sino-Nasal Outcome Test-16), used diagnostic tools and medications, and the management performed by primary care physicians (PCPs) and by otorhinolaryngologists (ORLs) were assessed.

RESULTS

Of the patients 36% were classified as having viral ARS, 63% postviral ARS and 1% as chronic rhinosinusitis. Working in a poorly air-conditioned environment was a risk factor (OR: 2.26, 95% CI 1.27 to 4.04) in developing postviral ARS. A higher number of diagnostic tools (rhinoscopy/endoscopy: 80% vs 70%; plain X-ray: 70% vs 55%; CT scan: 22% vs 12%; P<0.0001) were performed in postviral than viral cases. PCPs performed more X-rays than ORLs (P<0.0001). Patients, more those with postviral than viral ARS, received a high number of medications (oral antibiotics: 76% vs 62%; intranasal corticosteroids: 54% vs 38%; antihistamines: 46% vs 31%; mucolytic: 48% vs 60%; P<0.0001). PCPs prescribed more antibiotics, antihistamines and mucolytics than ORLs (P<0.0068). More patients with postviral than viral ARS reported symptoms of potential complications (1.5% vs 0.4%; P=0.0603). Independently of prescribed medications, quality of life was more affected in patients with postviral (38.7±14.2 vs 36.0±15.3; P=0.0031) than those with viral ARS. ARS resolution was obtained after 6.04 (viral) and 16.55 (postviral) days, with intranasal corticosteroids being associated with longer (OR: 1.07, 95% 1.02 to 1.12) and phytotherapy with shorter (OR: 0.95, 95% CI 0.91 to 1.00) duration.

CONCLUSIONS

There is a significant overuse of diagnostic tools and prescribed medications, predominantly oral antibiotics, by PCPs and ORLs, for viral and postviral ARS.

Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomised, double blind trial

Objective To investigate whether symptomatic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) is non-inferior to antibiotics in the treatment of uncomplicated lower urinary tract infection (UTI) in women, thus offering an opportunity to reduce antibiotic use in ambulatory care.Design Randomised, double blind, non-inferiority trial.Setting 17 general practices in Switzerland.Participants 253 women with uncomplicated lower UTI were randomly assigned 1:1 to symptomatic treatment with the NSAID diclofenac (n=133) or antibiotic treatment with norfloxacin (n=120). The randomisation sequence was computer generated, stratified by practice, blocked, and concealed using sealed, sequentially numbered drug containers.Main outcome measures The primary outcome was resolution of symptoms at day 3 (72 hours after randomisation and 12 hours after intake of the last study drug). The prespecified principal secondary outcome was the use of any antibiotic (including norfloxacin and fosfomycin as trial drugs) up to day 30. Analysis was by intention to treat.Results 72/133 (54%) women assigned to diclofenac and 96/120 (80%) assigned to norfloxacin experienced symptom resolution at day 3 (risk difference 27%, 95% confidence interval 15% to 38%, P=0.98 for non-inferiority, P<0.001 for superiority). The median time until resolution of symptoms was four days in the diclofenac group and two days in the norfloxacin group. A total of 82 (62%) women in the diclofenac group and 118 (98%) in the norfloxacin group used antibiotics up to day 30 (risk difference 37%, 28% to 46%, P<0.001 for superiority). Six women in the diclofenac group (5%) but none in the norfloxacin group received a clinical diagnosis of pyelonephritis (P=0.03).Conclusion Diclofenac is inferior to norfloxacin for symptom relief of UTI and is likely to be associated with an increased risk of pyelonephritis, even though it reduces antibiotic use in women with uncomplicated lower UTI.Trial registration ClinicalTrials.gov NCT01039545.

Antibiotic prescribing for acute respiratory tract infections in Norwegian primary care out-of-hours service

PURPOSE

To examine factors correlating with antibiotic prescribing for acute respiratory tract infections (ARTIs) in Norwegian primary care out-of-hours service.

MATERIALS AND METHODS

Retrospective data analysis for the year 2014 in two out-of-hours primary care units located in the towns of Hamar and Tønsberg in Norway, analysing type and frequency of different antibiotics prescribed by 117 medical doctors for ARTIs, and factors correlating with these.

RESULTS

The 117 doctors in two out-of-hours units diagnosed 6757 cases of ARTIs. 2310 (34.2%) of these resulted in an antibiotic prescription, where of 1615 (69.9%) were penicillin V (PcV). Tonsillitis and sinusitis were the two ARTI diagnoses with the highest antibiotic prescription rate. The antibiotic prescription rate increased successively with increasing activity level, measured as shorter median duration of consultations per session, from 28.7% (reference) in the least busy quintile of sessions to 36.6% (OR: 1.38 (95% CI =1.06-1.80)) in the busiest quintile of sessions. Prescribing of broad-spectrum antibiotics was not correlated with median duration of consultations per session. Female doctors had an OR of 0.61 (0.40-0.92) of a broad-spectrum antibiotic prescription compared to their male colleagues.

CONCLUSIONS

Antibiotic prescribing for ARTIs in the primary care out-of-hours services investigated is at the same level as in Norwegian general practice, but with a higher prescription rate of PcV. Antibiotic prescribing increases on busy sessions, measured as median duration of consultations per session. The work frame in primary care out-of-hours service might influence the quality of clinical decisions.

Antibiotics for acute respiratory tract infections: a mixed-methods study of patient experiences of non-medical prescriber management

OBJECTIVE

To (1) explore patients' expectations and experiences of nurse and pharmacist non-medical prescriber-led management of respiratory tract infections (RTIs), (2) examine whether patient expectations for antibiotics affect the likelihood of receiving them and (3) understand factors influencing patient satisfaction with RTI consultations.

DESIGN

Mixed methods.

SETTING

Primary care.

PARTICIPANTS

Questionnaires from 120 patients and follow-up interviews with 22 patients and 16 nurse and pharmacist non-medical prescribers (NMPs).

RESULTS

Patients had multiple expectations of their consultation with 43% expecting to be prescribed an antibiotic. There was alignment between self-reported patient expectations and those perceived by NMPs. Patient expectations for non-antibiotic strategies, such as education to promote self-management, were associated with receipt of those strategies, whereas patient expectations for an antibiotic were not associated with receipt of these medications. 'Patient-centred' management strategies (including reassurance and providing information) were received by 86.7% of patients. Regardless of patients' expectations or the management strategy employed, high levels of satisfaction were reported for all aspects of the consultation. Taking concerns seriously, conducting a physical examination, communicating the treatment plan, explaining treatment decisions and lack of time restrictions were each reported to contribute to patient satisfaction.

CONCLUSIONS

NMPs demonstrate an understanding of patient expectations of RTI consultations and use a range of non-antibiotic management strategies, particularly those resembling a patient-centred approach. Overall, patients' expectations were met and prescribers were not unduly influenced by patient expectations for an antibiotic. Patients were satisfied with the consultation, indicating that strategies used by NMPs were acceptable. However, the lower levels of satisfaction among patients who expected but did not receive an antibiotic indicates that although NMPs appear to have strategies for managing RTI consultations, there is still scope for improvement and these prescribers are therefore an important group to involve in antimicrobial stewardship.

WITHDRAWN: Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults

Review withdrawn from Issue 4, 2016. Review replaced by 'Systemic and topical antibiotics for chronic rhinosinusitis' (Head 2016).

The editorial group responsible for this previously published document have withdrawn it from publication.

WITHDRAWN: Antibiotics for acute maxillary sinusitis in adults

Currently, two separate Cochrane reviews, ‘Antibiotics for acute maxillary sinusitis in adults ’ and ‘Antibiotics for clinically diagnosed acute rhinosinusitis in adults ’ describe the effect of antibiotics for acute rhinosinusitis. Although both Cochrane reviews study the same condition, they look at different populations (patients in which the diagnosis was based on clinical signs and symptoms and patients in which the diagnosis was confirmed by imaging). Because of this, the conclusions are different in these Cochrane reviews. This was confusing for clinicians who needed to read both Cochrane reviews to know which conclusions are most applicable to their patients.
 
 This review is being withdrawn and will be incorporated into the updated publication of ‘Antibiotics for clinically diagnosed acute rhinosinusitis in adults ’. This ‘merged’ review will still maintain the relevant distinction between the two populations. However, information on the effectiveness of antibiotics for rhinosinusitis will be published in the ‘merged’ Cochrane review. We will omit the comparison between antibiotics (as published in this Cochrane review) because the choice for certain antibiotics and/or doses differs according to the local antibiotic resistance patterns and therefore this comparison is less relevant.

The editorial group responsible for this previously published document have withdrawn it from publication.

Medicolegal Implications of Common Rhinologic Medications

As otolaryngologists, we prescribe many medications to our patients. The objective of this article is to review the potential side effects and medicolegal risks of the common medications used to treat chronic rhinosinusitis. The authors evaluate some of the common side effects as well as the published literature on the lawsuits associated with those medications. Finally, the authors review the informed consent discussion and opportunities to improve patient care and decrease the risk of litigation.

Riniti e rinosinusiti acute dell’adulto

Le riniti e le rinosinusiti acute sono delle patologie frequenti e benigne nella maggior parte dei casi. La loro diagnosi è, prima di tutto, clinica. La difficoltà del loro trattamento è la differenziazione delle forme virali, più frequenti e banali, e delle forme batteriche, rare ma potenzialmente gravi. Le recenti raccomandazioni sono riassunte in questa esposizione. Analizzando le prove scientifiche del momento, esse insistono sui criteri diagnostici clinici, sulle indicazioni degli esami complementari, sull’efficacia dei vari trattamenti e sull’importanza dell’informazione e dell’educazione dei pazienti. I futuri lavori in questo settore dovranno permettere di selezionare in modo più preciso i pazienti che richiedono realmente una terapia antibiotica e di evitare, così, importanti spese sanitarie nonché la comparsa di ceppi batterici resistenti.

Inappropriate antibiotic prescribing and demand for antibiotics in patients with upper respiratory tract infections is hardly different in female versus male patients as seen in primary care

BACKGROUND

Unnecessary prescribing of antibiotics is a major public health concern. General practitioners (GPs) prescribe most antibiotics, often for upper respiratory tract infections (URTIs), and have in general been shown to prescribe antibiotics more often to women. No studies have examined the influence of patient gender on unnecessary antibiotic prescribing.

OBJECTIVES

To study a possible gender difference in unnecessary antibiotic prescriptions for URTIs in general practice; to assess whether a possible difference is explained by patient demand for antibiotics.

METHODS

Post-hoc analysis of a cross-sectional study including 15,022 patients with URTI (acute rhinitis, acute otitis media, acute sinusitis, acute pharyngotonsillitis) from Argentina, Denmark, Lithuania, Russia, Spain and Sweden (HAPPY AUDIT Project). The association between gender and unnecessary antibiotic prescriptions, unadjusted and adjusted for treatment demand, was analysed using logistic regression models.

RESULTS

A total of 25% of patients with URTI received antibiotics; in 45% of the cases, antibiotics were unnecessary. Overall, no gender difference for unnecessary prescribing of antibiotics for URTIs was found. Women with acute otitis media received an unnecessary antibiotic twice as often as men (14.4% versus 7.1%). In Danish patients with acute pharyngotonsillitis, there was a gender difference in unnecessary prescriptions for antibiotics (women 29.1% versus men 48.6%). Some 14% of patients receiving unnecessary antibiotics demonstrated a demand for antibiotics, but no gender difference was found in this group.

CONCLUSION

This study indicated a high rate of unnecessary antibiotic prescribing for URTIs in general practice, but overall found no gender differences in receiving unnecessary antibiotic prescriptions.

Rinitis y rinosinusitis agudas del adulto

Las rinitis y rinosinusitis agudas son afecciones frecuentes y benignas en la mayoría de los casos. Su diagnóstico es esencialmente clínico. La dificultad de su tratamiento consiste en diferenciar las formas víricas, más frecuentes y banales, de las formas bacterianas, que son infrecuentes pero potencialmente graves. En este artículo se resumen las recomendaciones recientes, que se basan en la evidencia actual e insisten en los criterios diagnósticos clínicos, las indicaciones de las pruebas complementarias, la eficacia de los distintos tratamientos, así como la importancia de la información y de la educación de los pacientes. Los futuros trabajos en este ámbito deberán permitir seleccionar con más precisión a los pacientes que requieren realmente una antibioticoterapia y evitar de ese modo unos gastos sanitarios considerables, así como la aparición de cepas bacterianas resistentes.

The prevalence of bacterial infection in acute rhinosinusitis: a Systematic review and meta-analysis

OBJECTIVES/HYPOTHESIS

To systematically assess the prevalence of bacterial infection in adults with acute rhinosinusitis (ARS).

METHODS

Electronic databases were systematically searched for relevant studies published up to June 2012.

RESULTS

Twenty-nine articles, evaluating a total of 9,595 patients with a clinical diagnosis of ARS, were included in the study. Of these, 14 (48%) studies required radiographic confirmation of sinusitis, one study (3%) required evidence of purulence, 10 studies (35%) required both for inclusion in the study population, and four studies (14%) required neither. The random effects model estimate of prevalence of bacterial growth on all cultures was 53.7% (CI 48.4%-59.0%), ranging from 52.5% (CI 46.7%-58.3%) in studies requiring radiographic confirmation of sinusitis to 61.1% (CI 54.0%-68.1%) in studies requiring neither radiographic evidence nor purulence on exam. Studies that obtained cultures from antral swab had a prevalence of bacterial growth of 61.0% (CI 54.7%-67.2%), whereas those utilizing endoscopic meatal sampling had a prevalence of 32.9% (CI 19.0%-46.8%).

CONCLUSIONS

Few studies evaluate the recovery of bacteria via culture in adults with a diagnosis of ABRS or ARS based on clinical criteria alone. With radiographic and/or endoscopic confirmation, antral puncture and endoscopically guided cultures produce positive bacterial cultures in approximately one-half of patients. Opportunities exist to improve diagnostic accuracy for bacterial infection in ARS.

Rhinosinusitis

Although sinusitis is common, controversy exists regarding terminology, diagnostic criteria, indications for imaging, and treatment guidelines. Patients who are diagnosed with bacterial sinusitis should be started on amoxicillin-clavulanate unless an allergy to penicillin is reported, in which case doxycycline or a respiratory fluoroquinolone is indicated for non-pregnant patients. Patients who fail to respond to antibiotic therapy should be suspected of having chronic sinusitis, which may requirea dditional therapy, including endoscopic surgery. Referral of these patients to an otolaryngologist for further evaluation is recommended. Patients with severe systemic symptoms including altered mental status or severe headaches should be suspected of having fungal sinusitis and to an otolaryngologist acutely because this condition has high mortality if not treated emergently.

Systemic corticosteroids for acute sinusitis

BACKGROUND

Acute sinusitis is the inflammation and swelling of the nasal and paranasal mucous membranes and is a common reason for patients to seek primary care consultations. The related impairment of daily functioning and quality of life is attributable to symptoms such as facial pain and nasal congestion.

OBJECTIVES

To assess the effects of systemic corticosteroids on clinical response rates and to determine adverse effects and relapse rates of systemic corticosteroids compared to placebo or standard clinical care in children and adults with acute sinusitis.

SEARCH METHODS

We searched CENTRAL (2014, Issue 1), MEDLINE (1966 to February week 1, 2014) and EMBASE (January 2009 to February 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing systemic corticosteroids to placebo or standard clinical care for patients with acute sinusitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of the trials and extracted data.

MAIN RESULTS

Five RCTs with a total of 1193 adult participants met our inclusion criteria. We judged methodological quality to be moderate in four trials and high in one trial. Acute sinusitis was defined clinically in all trials. However, the three trials performed in ear, nose and throat (ENT) outpatient clinics also used radiological assessment as part of their inclusion criteria. All participants were assigned to either oral corticosteroids (prednisone 24 mg to 80 mg daily or betamethasone 1 mg daily) or the control treatment (placebo in four trials and non-steroidal anti-inflammatory drugs (NSAIDs) in one trial). In four trials antibiotics were prescribed in addition to oral corticosteroids or control treatment, while one trial investigated the effects of oral corticosteroids as a monotherapy.When combining data from the five trials, participants treated with oral corticosteroids were more likely to have short-term resolution or improvement of symptoms than those receiving the control treatment: at days three to seven (risk ratio (RR) 1.3, 95% confidence interval (CI) 1.1 to 1.6; risk difference (RD) 17%, 95% CI 6% to 29%) and at days four to 14 (RR 1.2, 95% CI 1.0 to 1.5; RD 14%, 95% CI 1% to 27%). A sensitivity analysis including the four trials with placebo as a control treatment showed similar results but with a lesser effect size: at days three to seven (RR 1.2, 95% CI 1.1 to 1.3; RD 11%, 95% CI 4% to 17%) and days four to 14 (RR 1.1, 95% CI 1.0 to 1.2; RD 8%, 95% CI 2% to 13%). Statistical heterogeneity was high for many analyses. Subgroup analyses revealed that corticosteroid monotherapy had no beneficial effects. Furthermore, scenario analysis showed that outcomes missing from the trial reports might have introduced attrition bias (a worst-case scenario showed no statistically significant beneficial effect of oral corticosteroids). No trial reported effects on relapse or recurrence rates. Reported side effects in patients treated with oral corticosteroids were mild (nausea, vomiting, gastric complaints) and did not significantly differ from those receiving placebo.

AUTHORS' CONCLUSIONS

Oral corticosteroids as a monotherapy appear to be ineffective for adult patients with clinically diagnosed acute sinusitis. Current data on the use of oral corticosteroids as an adjunctive therapy to oral antibiotics are limited: almost all trials are performed in secondary care settings and there is a significant risk of bias. This limited evidence suggests that oral corticosteroids in combination with antibiotics may be modestly beneficial for short-term relief of symptoms in acute sinusitis, with a number needed to treat to benefit of seven for resolution or symptom improvement. A large primary care factorial trial is needed to establish whether oral corticosteroids offer additional benefits over antibiotics in acute sinusitis.

Antibiotics for acute maxillary sinusitis in adults

BACKGROUND

Sinusitis is one of the most common diagnoses among adults in ambulatory care, accounting for 15% to 21% of all adult outpatient antibiotic prescriptions. However, the role of antibiotics for sinusitis is controversial.

OBJECTIVES

To assess the effects of antibiotics in adults with acute maxillary sinusitis by comparing antibiotics with placebo, antibiotics from different classes and the side effects of different treatments.

SEARCH METHODS

We searched CENTRAL 2013, Issue 2, MEDLINE (1946 to March week 3, 2013), EMBASE (1974 to March 2013), SIGLE (OpenSIGLE, later OpenGrey (accessed 15 January 2013)), reference lists of the identified trials and systematic reviews of placebo-controlled studies. We also searched for ongoing trials via ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). We imposed no language or publication restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotics with placebo or antibiotics from different classes for acute maxillary sinusitis in adults. We included trials with clinically diagnosed acute sinusitis, confirmed or not by imaging or bacterial culture.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed trial quality. We calculated risk ratios (RRs) for differences between intervention and control groups in whether the treatment failed or not. All measures are presented with 95% confidence intervals (CIs). We conducted the meta-analyses using either the fixed-effect or random-effects model. In meta-analyses of the placebo-controlled studies, we combined data across antibiotic classes. Primary outcomes were clinical failure rates at 7 to 15 days and 16 to 60 days follow-up. We used GRADEpro to assess the quality of the evidence.

MAIN RESULTS

We included 63 studies in this updated review; nine placebo-controlled studies involving 1915 participants (seven of the studies clearly conducted in primary care settings) and 54 studies comparing different classes of antibiotics (10 different comparisons). Five studies at low risk of bias comparing penicillin or amoxicillin to placebo provided information on the main outcome: clinical failure rate at 7 to 15 days follow-up, defined as a lack of full recovery or improvement, for participants with symptoms lasting at least seven days. In these studies antibiotics decreased the risk of clinical failure (pooled RR of 0.66, 95% CI 0.47 to 0.94, 1084 participants randomised, 1058 evaluated, moderate quality evidence). However, the clinical benefit was small. Cure or improvement rates were high in both the placebo group (86%) and the antibiotic group (91%) in these five studies. When clinical failure was defined as a lack of full recovery (n = five studies), results were similar: antibiotics decreased the risk of failure (pooled RR of 0.73, 95% CI 0.63 to 0.85, high quality evidence) at 7 to 15 days follow-up.Adverse effects in seven of the nine placebo-controlled studies (comparing penicillin, amoxicillin, azithromycin or moxicillin to placebo) were more common in antibiotic than in placebo groups (median of difference between groups 10.5%, range 2% to 23%). However, drop-outs due to adverse effects were rare in both groups: 1.5% in antibiotic groups and 1% in control groups.In the 10 head-to-head comparisons, none of the antibiotic preparations were superior to another. However, amoxicillin-clavulanate had significantly more drop-outs due to adverse effects than cephalosporins and macrolides.

AUTHORS' CONCLUSIONS

There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, about 80% of participants treated without antibiotics improved 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 levels.

Intranasal steroids for acute sinusitis

BACKGROUND

Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school.

OBJECTIVES

We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis in adults and children.

SEARCH METHODS

We searched CENTRAL 2013, Issue 4, MEDLINE (January 1966 to May week 2, 2013), EMBASE (1990 to May 2013) and bibliographies of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing INCS treatment to placebo or no intervention in adults and children with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop-outs before the end of the study, rates of relapse, complications and return to school or work.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed trial quality and resolved discrepancies by consensus.

MAIN RESULTS

No new trials were found for inclusion in this update. Four studies involving 1943 participants with acute sinusitis met our inclusion criteria. The trials were well-designed and double-blind and studied INCS versus placebo or no intervention for 15 or 21 days. The rates of loss to follow-up were 7%, 11%, 41% and 10%. When we combined the results from the three trials included in the meta-analysis, participants receiving INCS were more likely to experience resolution or improvement in symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% confidence interval (CI) 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement of symptoms or complete relief: for mometasone furoate 400 µg versus 200 µg (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop-out and recurrence rates for the two treatment groups and for groups receiving higher doses of INCS.

AUTHORS' CONCLUSIONS

Current evidence is limited for acute sinusitis confirmed by radiology or nasal endoscopy but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy.

Acute post-operative rhinosinusitis following endonasal dacryocystorhinostomy

PURPOSE

To investigate the incidence and risk factors for acute rhinosinusitis (ARS) following endoscopic dacryocystorhinostomy (EnDCR).

METHODS

Retrospective single-surgeon interventional case series, including 196 consecutive patients undergoing 203 endonasal DCR, with clinical and radiological evidence of nasolacrimal duct or common canalicular obstruction. Pre-operative lacrimal and sinonasal clinical assessment and imaging, intraoperative endoscopic video recording, and post-operative clinical and endoscopic findings were analysed for cases of ARS occurring within the first 4 weeks following DCR among patients with and without a past history of chronic rhinosinusitis (CRS). Surgical complications and outcomes at 12 months and management of ARS are reported.

RESULTS

Three patients (1.5%) developed ARS within the first 5 post-operative days, none of which had experienced peri-operative complications and all had a past history of CRS. The rate of CRS in this cohort of 196 patients was 10.2% (n=20), of which 15% (n=3) developed ARS, although none had symptoms of CRS at the time of surgery; one had undergone previous sinus surgery. Presenting symptoms of ARS included facial pain, tenderness over the affected sinus, and nasal discharge; all patients responded to oral antibiotic therapy.

DISCUSSION

The rate of ARS following EnDCR was 1.5%. In those with a prior history of CRS, it was 15% (P=0.009). ARS developed within the first post-operative week among patients with a past history of CRS, who were asymptomatic at the time of surgery, and responded to oral antibiotics. CRS may be a risk factor for the development of post-operative ARS.

Antibiotic prescribing in patients with acute rhinosinusitis is not in agreement with European recommendations

OBJECTIVE

To assess the potential overprescribing in patients with acute rhinosinusitis across six countries with different antibiotic prescribing rates and different prevalence of antibiotic resistance.

DESIGN, SETTING AND SUBJECTS

A cross-sectional study including GPs from two Nordic countries, two Baltic countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) during three weeks in January 2008 as part of the EU-funded project "Health Alliance for Prudent Prescribing, Yield And Use of antimicrobial Drugs In the Treatment of respiratory tract infections" (HAPPY AUDIT).

MAIN OUTCOME MEASURES

Use of antibiotics for acute rhinosinusitis based on the recommendations in the European Position Paper on Rhinosinusitis and Nasal Polyps 2007 (EP3OS).

RESULTS

In total, 618 participating GPs registered 33 273 patients with RTI of whom 1150 (3.46%) were considered to have acute rhinosinusitis. Over 50% of the patients with acute rhinosinusitis had symptoms for < 5 days and 81% were prescribed antibiotics. In total, 68% of the patients included were not prescribed antibiotics according to guidelines; 45% had symptoms < 5 days or no fever (possible overprescribing) and 23% had symptoms < 5 days and no fever (probable overprescribing).

CONCLUSION

A considerable number of patients with symptoms of acute rhinosinusitis were not managed according to European recommendations (EP3OS guidelines). To prevent overprescribing, efforts should be made to implement the recommendations in daily practice.

Complementary and integrative treatments: rhinosinusitis

Rhinosinusitis is characterized by inflammation of the mucosa involving the paranasal sinuses and the nasal cavity and is one of the most common health care problems, with significant impairment of quality of life. There is a growing amount of interest in the use of complementary and integrative medicine for the treatment of rhinosinusitis. This article focuses on an integrative approach to rhinosinusitis.

Use of an electronic health record clinical decision support tool to improve antibiotic prescribing for acute respiratory infections: the ABX-TRIP study

BACKGROUND

Antibiotics are often inappropriately prescribed for acute respiratory infections (ARIs).

OBJECTIVE

To assess the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs.

DESIGN

A two-phase, 27-month demonstration project.

SETTING

Nine primary care practices in PPRNet, a practice-based research network whose members use a common electronic health record (EHR).

PARTICIPANTS

Thirty-nine providers were included in the project.

INTERVENTION

A CDSS was designed as an EHR progress note template. To facilitate CDSS implementation, each practice participated in two to three site visits, sent representatives to two project meetings, and received quarterly performance reports on antibiotic prescribing for ARIs.

MAIN OUTCOME MEASURES

1) Use of antibiotics for inappropriate indications. 2) Use of broad spectrum antibiotics when inappropriate. 3) Use of antibiotics for sinusitis and bronchitis.

KEY RESULTS

The CDSS was used 38,592 times during the 27-month intervention; its use was sustained for the study duration. Use of antibiotics for encounters at which diagnoses for which antibiotics are rarely appropriate did not significantly change through the course of the study (estimated 27-month change, 1.57% [95% CI, -5.35%, 8.49%] in adults and -1.89% [95% CI, -9.03%, 5.26%] in children). However, use of broad spectrum antibiotics for ARI encounters improved significantly (estimated 27 month change, -16.30%, [95% CI, -24.81%, -7.79%] in adults and -16.30 [95%CI, -23.29%, -9.31%] in children). Prescribing for bronchitis did not change significantly, but use of broad spectrum antibiotics for sinusitis declined.

CONCLUSIONS

This multi-method intervention appears to have had a sustained impact on reducing the use of broad spectrum antibiotics for ARIs. This intervention shows promise for promoting judicious antibiotic use in primary care.

Variations in antibiotic prescribing of acute rhinosinusitis in United States ambulatory settings

OBJECTIVE

To identify variations in antibiotic treatment of acute rhinosinusitis (ARS) on a national level.

STUDY DESIGN

Cross-sectional study of a national database.

SETTING

Otolaryngology and primary care ambulatory settings.

SUBJECTS AND METHODS

A nationally representative sample of adult outpatient visits was extracted from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey data for 2006 to 2009. Antibiotic prescriptions associated with ARS were tabulated. Statistical analyses were conducted to identify variations in antibiotic prescribing by patient and physician characteristics.

RESULTS

Antibiotics were prescribed in 82.3% ± 2.6% of 18.7 million visits for ARS (mean age, 46.2 years; 65.9% female). The ratio of primary care physician (PCP) to otolaryngologist (ENT) ARS visits was 18.6:1. Antibiotic prescription rates were inversely related to increasing age groups of 18 to 39, 40 to 64, and ≥ 65 years (87.8%, 81.2%, and 71.0%, respectively; P = .02). Physicians in general medicine outpatient departments, internal medicine, and family medicine were more likely to prescribe antibiotics compared with ENTs (adjusted odds ratio [OR], 7.9 [95% confidence interval (CI), 3.5-17.8]; 6.9 [2.5-19.2]; and 3.9 [2.0-7.7], respectively). The most commonly prescribed antibiotics were azithromycin, amoxicillin, and amoxicillin/clavulanate acid (27.5%, 15.5%, and 14.6%, respectively). The ENTs selected broad-spectrum antibiotics more often than PCPs (94.3% vs 75.7% of visits with antibiotics were broad-spectrum agents; P = .01).

CONCLUSION

Antibiotics were prescribed frequently despite recent consensus guidelines that discourage antibiotic use in mild cases. Furthermore, antibiotic prescription was more likely for younger patients and in primary care settings. This highlights the need to promote awareness of practice guidelines.

Characterisation of patients receiving moxifloxacin for acute bacterial rhinosinusitis in clinical practice: results from an international, observational cohort study

We conducted a prospective, non-controlled, multi-centre Phase IV observational cohort study of patients with acute bacterial rhinosinusitis who were treated with moxifloxacin in clinical practice in 19 countries in Asia Pacific, Europe and the Middle East. With the data collected we evaluated the presentation and course of the current disease episode, particularly in terms of the principal clinical signs and symptoms of acute rhinosinusitis and diagnostic procedures. A final assessment of moxifloxacin therapy was made to evaluate the impact of the sinusitis episode on activities of daily life and on sleep disturbance, and to evaluate the clinical outcome of treatment. A total of 7,090 patients were enrolled, of whom 3909 (57.6%) were included in the valid for clinical outcome and safety population. Regional differences were observed in the main symptoms of acute rhinosinusitis and, according to several characteristics, disease episodes appeared to be more severe in patients in Europe than in the Asia Pacific or Middle East regions. The sinusitis episode impacted on daily living for mean (SD) periods of 3.6 (3.2), 4.6 (3.9) and 3.1 (3.0) days and disturbed sleep for 3.6 (3.2), 4.6 (3.9) and 3.1 (3.0) nights in the Asia Pacific, Europe and Middle East regions, respectively. With moxifloxacin treatment, the mean (SD) time to improvement of symptoms was 3.0 (1.5), 3.4 (1.6) and 3.2 (1.5) days, and the time to resolution of symptoms was 4.8 (2.6) days, 5.7 (2.4) days and 5.5 (2.5) days, in the Asia Pacific, Europe and Middle East regions, respectively. In conclusion, acute rhinosinusitis remains a substantial health burden with significant impact on patients’ quality of life, and there are differences between global regions in the clinical presentation, diagnosis and clinical course of disease episodes. Moxifloxacin was an effective and well-tolerated treatment option in the overall population.

Registration: ClinicalTrials.gov Identifier: NCT00930488

Fluticasone furoate nasal spray reduces symptoms of uncomplicated acute rhinosinusitis: a randomised placebo-controlled study

BACKGROUND

Uncomplicated acute rhinosinusitis (ARS) is usually a self-limiting inflammatory condition often treated with antibiotics.

AIMS

To assess the safety and efficacy of fluticasone furoate nasal spray (FFNS) compared with placebo for symptomatic relief of uncomplicated ARS.

METHODS

A randomised, double-blind, placebo-controlled, parallel-group, multicentre, 2-week treatment study of FFNS 110 μg once and twice daily was undertaken in adults/adolescents.

RESULTS

A statistically significant reduction was seen in the daily major symptoms score, a composite score of three individual symptoms (nasal congestion/stuffiness, sinus headache/pressure or facial pain/pressure, and postnasal drip on a 0-3 scale) by both FFNS doses compared with placebo (least square mean differences vs. placebo of -0.386 (p=0.008) and -0.357 (p=0.014) for once daily and twice daily FFNS, respectively). The differences in median times to symptom improvement were not statistically significant between each dose of FFNS (7 days) and placebo (8 days). There were no treatment differences in antibiotic use for possible fulminant bacterial rhinosinusitis (3% in each group). The safety profile of FFNS was similar to placebo.

CONCLUSIONS

FFNS reduces symptoms of uncomplicated ARS compared with placebo and is well tolerated, providing support for withholding antibiotics in selected patients.

Pediatric urinary tract infection: does the evidence support aggressively pursuing the diagnosis?

The epidemiology of pediatric fever has changed considerably during the past 2 decades with the development of vaccines against the most common bacterial pathogens causing bacteremia and meningitis. The decreasing incidence of these 2 conditions among vaccinated children has led to an emphasis on urinary tract infection as a remaining source of potentially hidden infections in febrile children. Emerging literature, however, has led to questions about both the degree and nature of the danger posed by urinary tract infection in nonverbal children, whereas the aggressive pursuit of the diagnosis consumes resources and leads to patient discomfort, medical risks, and potential overdiagnosis. We review both early and emerging literature to examine the utility and efficacy of early identification and treatment of urinary tract infection in children younger than 24 months. We conclude that in well children of this age, it may be reasonable to withhold or delay testing for urinary tract infection if signs of other sources are apparent or if the fever has been present for fewer than 4 to 5 days.

Antibiotics for clinically diagnosed acute rhinosinusitis in adults

BACKGROUND

In primary care settings, the diagnosis of rhinosinusitis is generally based on clinical signs and symptoms. Technical investigations are not routinely performed, nor recommended. Individual trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear.

OBJECTIVES

To assess the effect of antibiotics in adults with clinically diagnosed rhinosinusitis in primary care settings.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2012), MEDLINE (January 1950 to February week 4, 2012) and EMBASE (January 1974 to February 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of antibiotics versus placebo in participants with rhinosinusitis-like signs or symptoms.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias. We contacted trial authors for additional information. We collected information on adverse effects from the trials.

MAIN RESULTS

We included 10 trials involving 2450 participants. Overall, the risk of bias in these studies was low. Irrespective of the treatment group, 47% of participants were cured after one week and 71% after 14 days. Antibiotics can shorten the time to cure, but only five more participants per 100 will cure faster at any time point between 7 and 14 days if they receive antibiotics instead of placebo (number needed to treat to benefit (NNTB)) 18 (95% confidence interval (CI) 10 to 115, I(2) statistic 0%, eight trials). Purulent secretion resolves faster with antibiotics (odds ratio (OR) 1.58 (95% CI 1.13 to 2.22)), (NNTB 11, 95% CI 6 to 51, I(2) statistic 0%, three trials). However, 27% of the participants who received antibiotics and 15% of those who received placebo experienced adverse events (OR 2.10, 95% CI 1.60 to 2.77) (number needed to treat to harm (NNTH)) 8 (95% CI 6 to 13, I(2) statistic 13%, seven trials). More participants in the placebo group needed to start antibiotic therapy because of an abnormal course of rhinosinusitis (OR 0.49, 95% CI 0.36 to 0.66), NNTH 20 (95% CI 14 to 35, I(2) statistic 0%, eight trials). Only one disease-related complication (brain abscess) occurred in a patient treated with antibiotics.

AUTHORS' CONCLUSIONS

The potential benefit of antibiotics in the treatment of clinically diagnosed acute rhinosinusitis needs to be seen in the context of a high prevalence of adverse events. Taking into account antibiotic resistance and the very low incidence of serious complications, we conclude that there is no place for antibiotics for the patient with clinically diagnosed, uncomplicated acute rhinosinusitis. This review cannot make recommendations for children, patients with a suppressed immune system and patients with severe disease, as these populations were not included in the available trials.

High costs and burden of illness in acute rhinosinusitis: real-life treatment patterns and outcomes in Swedish primary care

BACKGROUND

Few studies have investigated the impact of acute rhinosinusitis on disease-specific quality of life, and disease costs have not been studied previously in Scandinavia.

AIMS

To study symptoms, treatment patterns, quality of life and costs in adults with acute rhinosinusitis.

METHODS

This was an observational study in primary care. Patients aged 18-80 years seeking care for acute rhinosinusitis were evaluated using the Major Symptom Score (MSS) on days 0 and 15. Recommended and used treatments, quality of life and costs were assessed by questionnaires including EQ-5D™ and a visual analogue scale (VAS) on the same days.

RESULTS

150 patients were enrolled; 143 provided follow-up data. The proportion of MSS responders was 91%. Mean MSS decreased from 8.4 on day 0 (N = 150) to 1.9 on day 15 (N = 143). Patients reporting pain/discomfort and problems with usual activities decreased from 88.4% to 31.5% and from 43.2% to 1.4%, respectively, and mean VAS increased from 58.7 to 79.5. Intranasal corticosteroids were the most recommended and/or prescribed drugs. Total cost for an episode was 10,260 SEK (€1,102), of which 75% were indirect costs.

CONCLUSIONS

With treatment dominated by intranasal corticosteroids, a high proportion of responders and good symptom relief were seen. Acute rhinosinusitis seems to cause a high burden on quality of life and also a high cost for society.

Systemic corticosteroid monotherapy for clinically diagnosed acute rhinosinusitis: a randomized controlled trial

BACKGROUND

Patients with acute rhinosinusitis are frequently encountered in primary care. Although corticosteroids are being increasingly used for symptom control, evidence supporting their use is inconclusive. We conducted a randomized controlled trial to examine the effectiveness of systemic corticosteroid monotherapy for clinically diagnosed, uncomplicated acute rhinosinusitis.

METHODS

We conducted a block-randomized, double-blind, placebo-controlled clinical trial at 54 primary care practices (68 family physicians) in the Netherlands between Dec. 30, 2008, and Apr. 28, 2011. Adult patients with clinically diagnosed acute rhinosinusitis were randomly assigned to receive either prednisolone 30 mg/d or placebo for 7 days and asked to complete a symptom diary for 14 days. The primary outcome measure was the proportion of patients with resolution of facial pain or pressure on day 7.

RESULTS

Of the 185 patients included in the trial (93 in the treatment group, 92 in the placebo group), 2 withdrew from the study and 9 were excluded from the primary analysis because of incomplete symptom reporting. The remaining 174 patients (88 in the treatment group, 86 in the placebo group) were included in the intention-to-treat analysis. The proportions of patients with resolution of facial pain or pressure on day 7 were 62.5% (55/88) in the prednisolone group and 55.8% (48/86) in the placebo group (absolute risk difference 6.7%, 95% confidence interval -7.9% to 21.2%). The groups were similar with regard to the decrease over time in the proportion of patients with total symptoms (combined symptoms of runny nose, postnasal discharge, nasal congestion, cough and facial pain) and health-related quality of life. Adverse events were mild and did not differ significantly between the groups.

INTERPRETATION

Systemic corticosteroid monotherapy had no clinically relevant beneficial effects among patients with clinically diagnosed acute rhinosinusitis. Netherlands Trial Register registration no. 1295 (www.trialregister.nl/trialreg/index.asp).

Intranasal corticosteroids in management of acute sinusitis: a systematic review and meta-analysis

PURPOSE

Acute sinusitis is a common condition in ambulatory care, where it is frequently treated with antibiotics, despite little evidence of their benefit. Intranasal corticosteroids might relieve symptoms; however, evidence for this benefit is currently unclear. We performed a systematic review and meta-analysis of the effects of intranasal corticosteroids on the symptoms of acute sinusitis.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central register of Controlled Trials (CENTRAL), and Centre for Reviews and Dissemination databases until February 2011 for studies comparing intranasal corticosteroids with placebo in children or adults having clinical symptoms and signs of acute sinusitis or rhinosinusitis in ambulatory settings. We excluded chronic/allergic sinusitis. Two authors independently extracted data and assessed the studies' methodologic quality.

RESULTS

We included 6 studies having a total of 2,495 patients. In 5 studies, antibiotics were prescribed in addition to corticosteroids or placebo. Intranasal corticosteroids resulted in a significant, small increase in resolution of or improvement in symptoms at days 14 to 21 (risk difference [RD] = 0.08; 95% CI, 0.03-0.13). Analysis of individual symptom scores revealed most consistently significant benefits for facial pain and congestion. Subgroup analysis by time of reported outcomes showed a significant beneficial effect at 21 days (RD = 0.11; 95% CI, 0.06-0.17), but not at 14 to 15 days (RD = 0.05; 95% CI, -0.01 to 0.11). Meta-regression analysis of trials using different doses of mometasone furoate showed a significant dose-response relationship (P=.02).

CONCLUSIONS

Intranasal corticosteroids offer a small therapeutic benefit in acute sinusitis, which may be greater with high doses and with courses of 21 days' duration. Further trials are needed in antibiotic-naïve patients.

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults

Evidence-based guidelines for the diagnosis and initial management of suspected acute bacterial rhinosinusitis in adults and children were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America comprising clinicians and investigators representing internal medicine, pediatrics, emergency medicine, otolaryngology, public health, epidemiology, and adult and pediatric infectious disease specialties. Recommendations for diagnosis, laboratory investigation, and empiric antimicrobial and adjunctive therapy were developed.

Amoxicillin for acute rhinosinusitis: a randomized controlled trial

CONTEXT

Evidence to support antibiotic treatment for acute rhinosinusitis is limited, yet antibiotics are commonly used.

OBJECTIVE

To determine the incremental effect of amoxicillin treatment over symptomatic treatments for adults with clinically diagnosed acute rhinosinusitis.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, placebo-controlled trial of adults with uncomplicated, acute rhinosinusitis were recruited from 10 community practices in Missouri between November 1, 2006, and May 1, 2009.

INTERVENTIONS

Ten-day course of either amoxicillin (1500 mg/d) or placebo administered in 3 doses per day. All patients received a 5- to 7-day supply of symptomatic treatments for pain, fever, cough, and nasal congestion to use as needed.

MAIN OUTCOME MEASURES

The primary outcome was improvement in disease-specific quality of life after 3 to 4 days of treatment assessed with the Sinonasal Outcome Test-16 (minimally important difference of 0.5 units on a 0-3 scale). Secondary outcomes included the patient's retrospective assessment of change in sinus symptoms and functional status, recurrence or relapse, and satisfaction with and adverse effects of treatment. Outcomes were assessed by telephone interview at days 3, 7, 10, and 28.

RESULTS

A total of 166 adults (36% male; 78% with white race) were randomized to amoxicillin (n = 85) or placebo (n = 81); 92% concurrently used 1 or more symptomatic treatments (94% for amoxicillin group vs 90% for control group; P = .34). The mean change in Sinonasal Outcome Test-16 scores was not significantly different between groups on day 3 (decrease of 0.59 in the amoxicillin group and 0.54 in the control group; mean difference between groups of 0.03 [95% CI, -0.12 to 0.19]) and on day 10 (mean difference between groups of 0.01 [95% CI, -0.13 to 0.15]), but differed at day 7 favoring amoxicillin (mean difference between groups of 0.19 [95% CI, 0.024 to 0.35]). There was no statistically significant difference in reported symptom improvement at day 3 (37% for amoxicillin group vs 34% for control group; P = .67) or at day 10 (78% vs 80%, respectively; P = .71), whereas at day 7 more participants treated with amoxicillin reported symptom improvement (74% vs 56%, respectively; P = .02). No between-group differences were found for any other secondary outcomes. No serious adverse events occurred.

CONCLUSION

Among patients with acute rhinosinusitis, a 10-day course of amoxicillin compared with placebo did not reduce symptoms at day 3 of treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00377403.

Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial

OBJECTIVE

To evaluate the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care.

DESIGN

Randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation.

SETTING

68 general practices with about 480,000 patients in Wales, United Kingdom.

PARTICIPANTS

34 practices were randomised to receive the educational programme and 34 practices to be controls. 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed.

INTERVENTIONS

Intervention practices followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice based seminar reflecting on the practices' own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care.

MAIN OUTCOME MEASURES

Total numbers of oral antibiotic items dispensed for all causes per 1000 practice patients in the year after the intervention, adjusted for the previous year's dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes, and costs.

RESULTS

The rate of oral antibiotic dispensing (items per 1000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% confidence interval 0.6% to 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (P=0.02). Reductions were found for all classes of antibiotics other than penicillinase-resistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4% to 13.7%) and macrolides (7.7%, 1.1% to 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within seven days of an index consultation. The mean cost of the programme was £2923 (€3491, $4572) per practice (SD £1187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (-0.4% to 11.4%), equivalent to a reduction of about £830 a year for an average intervention practice.

CONCLUSION

The STAR educational programme led to reductions in all cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations, or costs. Trial registration ISRCT No 63355948.

Viral Disease, Air Pollutants, Nanoparticles, and Asthma

Health care providers who treat patients with respiratory disease are often asked by their patients, “What caused my asthma? And what causes my asthma suddenly to become worse?” These questions have always been difficult to answer, and moving directly to a discussion of the management of asthma is a much easier road to take. In recent years, though, enough information has accumulated about the causes of asthma that one can weave a story containing useful advice that may help patients participate in the management of their disease. And there are also recent studies that can provide answers to the questions posed by physicians who have watched in puzzlement as their previously well-controlled asthma patients have spiraled rapidly out of control. This story has been growing increasingly complex, with an ever-expanding cast of players that sometimes creates a tangled web of interactions.

Historical and clinical features of 200 cases of equine sinus disease

The historical and clinical findings in 200 referred cases of equine sinus disease were reviewed retrospectively. Univariable and multivariable analyses were performed to detect significant differences in historical or clinical features between various categories of sinus disease. The causes of sinus disease were classified as subacute primary (less than two months duration) (n=52), chronic primary (more than two months duration) (n=37), dental (n=40), sinus cyst (n=26), traumatic (n=13) or mycotic sinusitis (n=7), sinus neoplasia (n=10), dental-related oromaxillary fistula (n=8) and intrasinus progressive ethmoid haematoma (n=7). The majority of sinus disorders were of chronic duration at the time of referral and most (including 97 per cent of chronic primary sinusitis cases) had not responded to previous antibiotic therapy and/or sinus lavage in some cases. Clinical signs included unilateral nasal discharge in most cases, including purulent or mucopurulent discharge in all horses with primary, dental and mycotic sinusitis. Haemorrhagic nasal discharge was a feature of traumatic sinusitis and intrasinus progressive ethmoid haematomas. Firm facial swellings and nasal airflow obstruction were features of sinus cysts and neoplasms. Ipsilateral lymphadenitis was a more prominent feature of sinus disease with active infections such as primary, dental or mycotic sinusitis.

Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults

BACKGROUND

Chronic rhinosinusitis (CRS) is a common health problem which significantly affects quality of life. A wide range of medical and surgical therapies have been used to treat CRS. Both systemic and topical antibiotics are used with the aim of eliminating infection and inflammation, altering bacterial biofilm formation, reversing ostial occlusion and improving symptoms. Various groups of systemic antibiotics have been studied; clinical cure rates reported are inconsistent and range from 50% to 95%.

OBJECTIVES

To determine the effectiveness and adverse reactions associated with systemic antibiotic therapy for CRS in adults.

SEARCH STRATEGY

We searched the Cochrane ENT Group Trials Register; CENTRAL (2010, Issue 2); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 10 June 2010.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing systemic antibiotics with placebo for chronic rhinosinusitis in adults.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently, compared results and resolved disagreements by discussion. We assessed treatment effect by calculating the risk ratio (RR) and 95% confidence intervals (CI) of cure at a specific time point for each trial. We used mean difference (MD) and 95% CI for continuous variables (severity scores, duration of symptoms, etc.).

MAIN RESULTS

We included one study involving 64 patients. We assessed the overall risk of bias in this study as high. The study reported that roxithromycin could reduce the mean response score of patients by 0.73 points on a 1 to 6-point scale (95% CI 0.32 to 1.14, P = 0.0005) compared to those on placebo at three months after the start of treatment. This study also used sinonasal outcome test-20 (SNOT-20) comparing between pre and post-treatment at six, 12 and 24 weeks. The mean change in SNOT-20 from baseline at 24 weeks in the roxithromycin group was not significantly more than in the placebo group, at 0.27 points (95% CI -0.24 to 0.78, P = 0.30) on a 0 to 5-point scale.

AUTHORS' CONCLUSIONS

There is limited evidence from one small study to support the use of systemic antibiotics for the curative treatment of chronic rhinosinusitis in adults. Further good quality trials, with large sample sizes, are needed to evaluate the use of antibiotics in chronic rhinosinusitis.

Canadian clinical practice guidelines for acute and chronic rhinosinusitis

This document provides healthcare practitioners with information regarding the management of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) to enable them to better meet the needs of this patient population. These guidelines describe controversies in the management of acute bacterial rhinosinusitis (ABRS) and include recommendations that take into account changes in the bacteriologic landscape. Recent guidelines in ABRS have been released by American and European groups as recently as 2007, but these are either limited in their coverage of the subject of CRS, do not follow an evidence-based strategy, or omit relevant stakeholders in guidelines development, and do not address the particulars of the Canadian healthcare environment.

Advances in understanding the pathophysiology of CRS, along with the development of appropriate therapeutic strategies, have improved outcomes for patients with CRS. CRS now affects large numbers of patients globally and primary care practitioners are confronted by this disease on a daily basis. Although initially considered a chronic bacterial infection, CRS is now recognized as having multiple distinct components (eg, infection, inflammation), which have led to changes in therapeutic approaches (eg, increased use of corticosteroids). The role of bacteria in the persistence of chronic infections, and the roles of surgical and medical management are evolving. Although evidence is limited, guidance for managing patients with CRS would help practitioners less experienced in this area offer rational care. It is no longer reasonable to manage CRS as a prolonged version of ARS, but rather, specific therapeutic strategies adapted to pathogenesis must be developed and diffused.

Guidelines must take into account all available evidence and incorporate these in an unbiased fashion into management recommendations based on the quality of evidence, therapeutic benefit, and risks incurred. This document is focused on readability rather than completeness, yet covers relevant information, offers summaries of areas where considerable evidence exists, and provides recommendations with an assessment of strength of the evidence base and degree of endorsement by the multidisciplinary expert group preparing the document.

These guidelines have been copublished in both Allergy, Asthma & Clinical Immunology and the Journal of Otolaryngology-Head and Neck Surgery.

Effectiveness of antibiotics for acute sinusitis in real-life medical practice

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Determining bacterial aetiology of acute sinusitis is difficult without employing invasive procedures. Most episodes of acute sinusitis resolve spontaneously. Antibiotics have demonstrated efficacy for the treatment of acute bacterial sinusitis in clinical trials yet little is known of their effectiveness in real-life treatment settings.

WHAT THIS STUDY ADDS

Most cases of untreated acute sinusitis resolved spontaneously. Antibiotics were more effective when given within the first 10 days of treatment. This had no effect on later recurrence. Patients with poor oro-dental condition or recent antibiotic use may derive the most benefit from an antibiotic prescription and this should be considered by prescribers. The antibiotics used were found to be equally effective. Existing recommendations to identify acute sinusitis with high probability of bacterial origin, such as the French recommendations, fever or duration of symptoms fail to identify patients in whom antibiotics are more effective.

AIMS

To assess the effectiveness of antibiotics in acute bacterial sinusitis.

METHODS

This was a prospective cohort study with 2 months follow-up of 5640 patients with acute sinusitis included by a random sample from 1174 GPs and 120 ENT specialists. Main outcomes were short-term initial success, defined as the absence of prescription of (another) antibiotic or sinus lavage within 10 days, and lack of recurrence between the 11th and 60th day, after initial success.

RESULTS

Initial success was found in 88.7% (95% CI 85.1, 91.4%) of patients without antibiotic prescription at inclusion and 96.2% (95% CI 95.7, 96.7%) of patients prescribed antibiotics. The 10 day adjusted hazard ratio (HR) for treatment failure (new antibiotic prescription or sinus drainage) with initial antibiotics compared with no antibiotics was 0.30 (95% CI 0.21, 0.42) with no difference between antibiotics. Antibiotics were more effective in patients with poor oro-dental condition (HR 0.04, 95% CI 0.01, 0.20) and in patients who had already used antibiotics during the previous 2 months (HR 0.09, 95% CI 0.03, 0.28). For patients without failure at 10 days, recurrence between the 11th and 60th day was similar whether or not they had initially been prescribed an antibiotic, 94.1% (95% CI 93.4, 94.7%) and 93.4% (95%CI 90.3, 95.5%), respectively.

CONCLUSION

Most acute sinusitis cases not prescribed antibiotics resolve spontaneously. Antibiotics reduced by 3.3-fold the risk of failure within 10 days, without impact on later recurrence. The greatest benefit of antibiotics was found for patients with poor oro-dental condition or with antibiotic use within the previous 2 months.

A multicenter randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis (DIABOLO trial)

BACKGROUND

Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects.

METHODS

A randomized multicenter pragmatic clinical trial comparing two treatment strategies for uncomplicated acute diverticulitis. I) A conservative strategy with antibiotics: hospital admission, supportive measures and at least 48 hours of intravenous antibiotics which subsequently are switched to oral, if tolerated (for a total duration of antibiotic treatment of 10 days). II) A liberal strategy without antibiotics: admission only if needed on clinical grounds, supportive measures only. Patients are eligible for inclusion if they have a diagnosis of acute uncomplicated diverticulitis as demonstrated by radiological imaging. Only patients with stages 1a and 1b according to Hinchey's classification or "mild" diverticulitis according to the Ambrosetti criteria are included. The primary endpoint is time-to-full recovery within a 6-month follow-up period. Full recovery is defined as being discharged from the hospital, with a return to pre-illness activities, and VAS score below 4 without the use of daily pain medication. Secondary endpoints are proportion of patients who develop complicated diverticulitis requiring surgery or non-surgical intervention, morbidity, costs, health-related quality of life, readmission rate and acute diverticulitis recurrence rate. In a non-inferiority design 264 patients are needed in each study arm to detect a difference in time-to-full recovery of 5 days or more with a power of 85% and a confidence level of 95%. With an estimated one percent of patients lost to follow up, a total of 533 patients will be included.

CONCLUSION

A clinically relevant difference of more than 5 days in time-to-full recovery between the two treatment strategies is not expected. The liberal strategy without antibiotics and without the strict requirement for hospital admission is anticipated to be more a more cost-effective approach.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

NCT01111253.