Primary-care-based randomised placebo-controlled trial of antibiotic treatment in acute maxillary sinusitis

Man flu is not a thing - Gender-specific secondary analysis of a prospective randomized-controlled trial for acute rhinosinusitis

BACKGROUND

'Man flu' is a popular term to describe hypersensitivity to acute rhinosinusitis (ARS) in men. While this pop-cultural description may influence the social perspective of ARS, so far, no prospective observational data on the gender-specific natural development of ARS is available.

METHODS

Secondary data analyses were performed from the placebo arm of a prospective, interventional phase IV clinical trial. Objective measurement of ARS symptoms were assessed with the Major Symptom Score (MSS), a clinician-rated assessment tool. The Sino-Nasal Outcome Test-22 (SNOT-22) was used for symptom self-report. Repeated measures analysis of variance (ANOVA) with gender as a group variable were used to investigate changes in MMS and SNOT-22 total score and subscales over time.

RESULTS

While MMS scores did not differ at baseline, women showed a significantly greater reduction than men with a medium effect size (p = .040) over time. In the patient-reported symptom score, women showed a significantly higher symptom load at baseline (p = .038), but also a significantly faster subjective improvement of symptoms than men during the course of time with a medium effect size (p = .020). However, when separately assessing the SNOT-22 subscales, a significant time*gender effect was only found for emotional symptoms (p = .047). No gender effect was found for neither nasal, otological, or sleep symptoms (all p > .05).

DISCUSSION

Although a certain gender difference was found both in the clinician- as well as patient-rated ARS symptoms, the hypothesis of a 'man flu' should be disregarded. Gender differences in ARS symptomatology should be carefully evaluated without stigmatizing symptom distress based on gender perceptions.

Is there a role for antibiotics in the treatment of chronic rhinosinusitis?

Rhinosinusitis is one of the most common reasons for adult outpatient antibiotic prescriptions, though there is little clinical evidence to support this practice, especially for chronic rhinosinusitis. Despite considerable research, the etiology of chronic rhinosinusitis, including the pathogenic role of microbes, remains poorly understood. Rigorous studies of the efficacy of antibiotic treatment of chronic sinusitis are surprisingly few in number and the results are somewhat conflicting. This review article will review the rationales for and against the treatment of chronic rhinosinusitis with antibiotics, based on current evidence and understanding of pathophysiology, and will also summarize the current guidelines.

Clinical decision support system RHINA in the diagnosis and treatment of acute or chronic rhinosinusitis

Background

Rhinosinusitis is an inflammation of the sinonasal cavity which affects roughly one in seven people per year. Acute rhinosinusitis (ARS) is mostly, apart from allergic etiology, caused by a viral infection and, in some cases (30–50%), by a bacterial superinfection. Antibiotics, indicated only in rare cases according to EPOS guidelines, are nevertheless prescribed in more than 80% of ARS cases, which increases the resistant bacterial strains in the population.

Methods

We have designed a clinical decision support system (CDSS), RHINA, based on a web application created in HTML 5, using JavaScript, jQuery, CCS3 and PHP scripting language. The presented CDSS RHINA helps general physicians to decide whether or not to prescribe antibiotics in patients with rhinosinusitis.

Results

In a retrospective study of a total of 1465 patients with rhinosinusitis, the CDSS RHINA presented a 90.2% consistency with the diagnosis and treatment made by the ENT specialist.

Conclusion

Patients assessed with the assistance of our CDSS RHINA would decrease the over-prescription of antibiotics, which in turn would help to reduce the bacterial resistance to the most commonly prescribed antibiotics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01599-3.

Characteristic appearance of the oropharynx in patients with postnasal drip (PND)-induced cough

INTRODUCTION

Post-nasal drip (PND)-induced cough is a common cause of chronic cough. However, there is little known about the characteristic physical findings of this condition.

OBJECTIVES

We investigated views of the pharyngeal wall in patients with PND-induced cough using a handy endoscopic images.

METHODS

The subjects were 135 consecutive patients referred to our hospital with a sensation of something "dripping down the throat" as one of their symptoms. Physical findings for the oropharynx were examined using Wi-Fi endoscope camera. The difference in probability of symptoms in patients with acute cough and those with subacute/chronic cough was assessed using a Bayesian Fisher exact test on a 2 × 2 table.

RESULTS

Among the patients, 105 (78%) complained of cough, 78 (58%) of acute cough, 20 (15%) of subacute cough, and 7 (5%) of chronic cough; and 71 (53%) had coexisting asthma. Using Bayesian inference, a sore or scratchy throat and fever were more common in patients with acute cough than in those with subacute/chronic cough. In endoscopic images of the oropharynx, a reddish curtain sign on the posterior pharyngeal wall behind the palatopharyngeal arch was found in 121 patients (90%).

CONCLUSION

Patients with acute PND-induced cough have a component of acute upper respiratory infection, because of high probability of a sore or scratchy throat and fever as symptom. A reddish curtain sign may be a useful finding for identifying PND-induced cough in these cases.

Antibiotic use and serious complications following acute otitis media and acute sinusitis: a retrospective cohort study

BACKGROUND

Most people with acute otitis media (AOM) and acute sinusitis (AS) do not benefit from antibiotics, and GPs are under increasing pressure to reduce antibiotic prescribing. Concern about the risk of complications can drive unnecessary prescribing.

AIM

To describe the incidence of serious complications following AOM and AS, and to determine whether antibiotics are protective.

DESIGN AND SETTING

This was a retrospective cohort study using the Clinical Practice Research Datalink database to identify patients diagnosed in general practice with AOM or AS between 1 January 1982 and 31 December 2012.

METHOD

The incidence of brain abscess and acute mastoiditis following AOM, and of brain abscess and orbital cellulitis following AS, were calculated, as was the association between antibiotics and the development of these complications and numbers needed to treat (NNT).

RESULTS

The incidence of brain abscess and acute mastoiditis following AOM were 0.03 (95% confidence interval [CI] = 0.01 to 0.20) and 5.62 (95% CI = 4.81 to 6.56) per 10 000 AOM episodes, respectively. The incidence of brain abscess and orbital cellulitis following AS was 0.11 (95% CI = 0.05 to 0.26) and 1.50 (95% CI = 1.17 to 1.90) per 10 000 AS episodes, respectively. Antibiotic prescription for AOM was associated with lower odds of developing acute mastoiditis (odds ratio [OR] 0.54; 95% CI = 0.37 to 0.79); NNT to prevent one case was 2181 (95% CI = 1196 to 5709). Antibiotic prescribing for AS was associated with lower odds of subsequent brain abscess (OR 0.12; 95% CI = 0.02 to 0.70); NNT to prevent one case was 19 988 (95% CI = 4951 to 167 099). No significant association between antibiotic prescription and development of orbital cellulitis following AS were found (OR 0.56; 95% CI = 0.27 to 1.12).

CONCLUSION

Serious complications following AOM and AS are rare. Antibiotics are associated with lower odds of developing complications, but the NNT are large.

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.

The Cost-Effectiveness of the Management of Acute Sinusitis

Background

Sinusitis is a common medical disease with a tremendous economic impact on health care. Our objective was to determine the most cost-effective strategy for the management of acute sinusitis from the societal and payers’ perspectives.

Methods

A Markov disease simulation model was used for comparing four treatment strategies: (1) no antibiotic (Abx), (2) empiric Abx, (3) CT-based Abx, and (4) clinical guideline-based Abx.

Results

Empiric Abx treatment was the most cost-effective from the societal perspective. Clinical guideline-based treatment was the most cost-effective strategy from the payers’ perspective ($38,515/quality-adjusted life year). Cost and effectiveness of Abx, time lost from work, and prevalence of acute bacterial sinusitis are influential variables.

Conclusion

Empiric Abx treatment is a cost-effective strategy from the short-term societal perspective. However, Abx resistance will lead to increased costs and reduced efficacy of this strategy in the long-term. Clinical guidelines provide a low-cost method of targeting therapy.

Chronic Rhinosinusitis and the Evolving Understanding of Microbial Ecology in Chronic Inflammatory Mucosal Disease

Chronic rhinosinusitis (CRS) encompasses a heterogeneous group of debilitating chronic inflammatory sinonasal diseases. Despite considerable research, the etiology of CRS remains poorly understood, and debate on potential roles of microbial communities is unresolved. Modern culture-independent (molecular) techniques have vastly improved our understanding of the microbiology of the human body. Recent studies that better capture the full complexity of the microbial communities associated with CRS reintroduce the possible importance of the microbiota either as a direct driver of disease or as being potentially involved in its exacerbation. This review presents a comprehensive discussion of the current understanding of bacterial, fungal, and viral associations with CRS, with a specific focus on the transition to the new perspective offered in recent years by modern technology in microbiological research. Clinical implications of this new perspective, including the role of antimicrobials, are discussed in depth. While principally framed within the context of CRS, this discussion also provides an analogue for reframing our understanding of many similarly complex and poorly understood chronic inflammatory diseases for which roles of microbes have been suggested but specific mechanisms of disease remain unclear. Finally, further technological advancements on the horizon, and current pressing questions for CRS microbiological research, are considered.

Evidence and evidence gaps in therapies of nasal obstruction and rhinosinusitis

Therapeutic decisions in otorhinolaryngology are based on clinical experience, surgical skills, and scientific evidence. Recently, evidence-based therapies have gained increased attention and importance due to their potential to improve the individual patient's treatment and their potential at the same time to reduce treatment costs. In clinical practice, it is almost impossible to stay ahead of the increasing mass of literature and on the other hand critically assess the presented data. A solid scientific and statistical knowledge as well as a significant amount of spare time are required to detect systematic bias and other errors in study designs, also with respect to assessing whether or not a study should be part of an individual therapeutic decision. Meta-analyses, reviews, and clinical guidelines are, therefore, of increasing importance for evidence-based therapy in clinical practice. This review is an update of the availability of external evidence for the treatment of nasal obstruction and rhinosinusitis. It becomes evident that both groups of diseases differ significantly in the availability of external evidence. Furthermore, it becomes obvious that surgical treatment options are normally based on evidence of significantly lower quality than medical treatment options.

Systematic review of antimicrobial therapy in patients with acute rhinosinusitis

OBJECTIVE

To estimate the natural history of acute rhinosinusitis and the impact of antimicrobial therapy on clinical outcomes.

DATA SOURCES

MEDLINE and Cochrane Trial Registry through February 2007 combined with manual review of retrieved article bibliographies.

REVIEW METHODS

Systematic review and random-effects meta-analysis of double-blind, randomized, controlled trials comparing placebo vs oral antimicrobial for initial therapy of uncomplicated acute rhinosinusitis in patients aged 12 years or older.

RESULTS

Thirteen trials met inclusion criteria and had data suitable for pooling. Clinical cure occurred in 8% of patients who received placebo after 3 to 5 days, rising to 35% by 7 to 12 days and 45% by 14 to 15 days. Antimicrobials increased cure rates at 7 to 12 days, with an absolute rate difference of 15% (95% CI, 4%-25%). Clinical improvement occurred in 30% of patients who received placebo after 3 to 5 days, rising to 73% by 7 to 12 days and 14 to 15 days. Antimicrobials increased improvement rates at 7 to 12 days by 14% (95% CI, 1%-28%) and at 14 to 15 days by 7% (95% CI, 2%-13%). Diarrhea and adverse events were about 80% more common in patients who received antimicrobials (P < 0.03).

CONCLUSIONS

Over 70% of patients with acute rhinosinusitis are improved after 7 days, with or without antimicrobial therapy. About 7 patients must be treated to achieve one additional positive outcome at 7 to 12 days above and beyond spontaneous resolution. Generalizability of results is limited because nearly all trials involved a primary care setting and some trials excluded patients with severe illness.

Antibiotic Treatment for First Episode of Acute Otitis Media Is Not Associated with Future Recurrences

OBJECTIVE

Antibiotic treatment of acute otitis media (AOM) has been suggested to increase the risk of future AOM episodes by causing unfavorable shifts in microbial flora. Because current evidence on this topic is inconclusive and long-term follow-up data are scarce, we wanted to estimate the effect of antibiotic treatment for a first AOM episode occurring during infancy on AOM recurrences and AOM-related health care utilization later in life.

METHODS

We obtained demographic information and risk factors from data of the Wheezing Illnesses Study Leidsche Rijn, a prospective birth cohort study in which all healthy newborns born in Leidsche Rijn (between 2001 and 2012), The Netherlands, were enrolled. These data were linked to children's primary care electronic health records up to the age of four. Children with at least one family physician-diagnosed AOM episode before the age of two were included in analyses. The exposure of interest was the prescription of oral antibiotics (yes vs no) for a child's first AOM episode before the age of two years.

RESULTS

848 children were included in analyses and 512 (60%) children were prescribed antibiotics for their first AOM episode. Antibiotic treatment was not associated with an increased risk of total AOM recurrences (adjusted rate ratio: 0.94, 95% CI: 0.78-1.13), recurrent AOM (≥3 episodes in 6 months or ≥4 in one year; adjusted risk ratio: 0.79, 95% CI: 0.57-1.11), or with increased AOM-related health care utilization during children's first four years of life.

CONCLUSIONS

Oral antibiotic treatment of a first AOM episode occurring during infancy does not affect the number of AOM recurrences and AOM-related health care utilization later in life. This information can be used when weighing the pros and cons of various AOM treatment options.

Management of Acute and Chronic Sinusitis in Adult Patients

Sinusitis is a highly prevalent illness in the United States resulting in significant sinus discomfort and pain. Diagnoses of sinusitis are typically based on patients’clinical presentations but are complicated because numerous microbiologic etiologies exist (viruses, bacteria, fungi). Along with its diagnosis, sinusitis should be classified as acute or chronic on the basis of the duration of symptoms. It is important to differentiate acute from chronic sinusitis because their etiologies and treatments may differ. Patients who present with symptoms of acute sinusitis for at least 1 week after an acute viral illness are appropriate candidates for antibiotics. Antibiotic choices should be based on local resistance patterns and patients’ characteristics, but a 2-week course of first-line antibiotics (eg, amoxicillin, trimethoprim-sulfamethoxazole) is usually sufficient. Compared to that of acute sinusitis, the management of chronic bacterial sinusitis is more complicated and controversial. Chronic sinusitis may be medically or surgically managed. Medical therapy of chronic bacterial sinusitis should consist of a prolonged course of antibiotics (4 to 6 weeks). Broad-spectrum antibiotics should be used, covering Staphylococcus aureus, • -lactamase-producing organisms, and in certain situations anaerobes. Adjunctive therapy with saline nasal spray, nasal decongestants, and inhaled nasal corticosteroids may be helpful for certain patients with acute or chronic sinusitis.

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.

Rhinosinusitis in morbidity registrations in Dutch General Practice: a retro-spective case-control study

Background

There is only limited accurate data on the epidemiology of rhinosinusitis in primary care.

This study was conducted to assess the incidence of acute and chronic rhinosinusitis by analysing data from two Dutch general practice registration projects. Several patient characteristics and diseases are related to the diagnosis rhinosinusitis.

Methods

The Continuous Morbidity Registration (CMR) and the Transitionproject (TP) are used to analyse the data on rhinosinusitis in primary practice. Both registries use codes to register diagnoses.

Results

In the CMR 3244 patients are registered with rhinosinusitis and in the TP 5424 CMR: The absolute incidence of (acute) rhinosinusitis is 5191 (18.8 per 1000 patient years). Regarding an odds ratio of 5.58, having nasal polyps is strongest related to rhinosinusitis compared to the other evaluated comorbidities. A separate code for chronic rhinosinusitis exists, but is not in use.

TP: Acute and chronic rhinosinusitis are coded as one diagnosis. The incidence of rhinosinusitis is 5574 or 28.7 per 1000 patient years. Patients who visit their general practitioner with “symptoms/complaints of sinus”, allergic rhinitis and “other diseases of the respiratory system” have the highest chances to be diagnosed with rhinosinusitis. Medication is prescribed in 90.6 % of the cases.

Conclusions

Rhinosinusitis is a common diagnosis in primary practice. In the used registries no difference could be made between acute and chronic rhinosinusitis, but they give insight in comorbidity and interventions taken by the GP in case of rhinosinusitis.

Acute sinusitis

Clinical diagnosis of acute sinusitis is troublesome because it involves use of a cluster of diagnostic criteria that have only moderate sensitivity. Ancillary testing with radiography or antral puncture is impractical, expensive, and usually unnecessary in the primary care setting. Antibiotic therapy is not beneficial for most patients in whom acute sinusitis is suspected, even when radiographic abnormalities are found. Simple management algorithms and patient information are now available to aid primary care physicians in offering appropriate therapeutic measures and reassuring patients who are expecting "'a pill for every ill' when that pill is an antibacterial."

The use of large volume low pressure nasal saline with fluticasone propionate for the treatment of pediatric acute rhinosinusitis

OBJECTIVES

Fluticasone propionate and nasal saline irrigation have been used in the treatment of sinonasal diseases for a long time. Our study investigates the effect of the combination of large volume low pressure nasal saline irrigation and fluticasone propionate for the treatment of pediatric acute rhinosinusitis.

METHODS

Ninety-one pediatric patients with acute rhinosinusitis were included in our study. The patients were randomized into two groups. The first group (n=45) was treated with standard therapy (antibiotherapy+nasal decongestant) for 2 weeks, the second group was treated with the large volume low pressure nasal saline+fluticasone propionate combination for 3 weeks. The clinical scores, radiologic evaluations (X-ray Waters view), peak nasal inspiratory flow (PNIF) measurements, total symptom scores and hematologic parameters (WBC, CRP, ESR) of the patients were evaluated and compared.

RESULTS

There were no significant differences in between the two groups regarding age, gender, height and weight. Even though the clinical scores of Group 2 improved more rapidly, there were no significant differences in between groups regarding clinical scores by the 21st day. There were no significant differences in post treatment radiologic evaluations (Waters graphy). Both groups had significant improvement of their post treatment PNIF values, yet the improvement was more marked in Group 2 than in Group 1. The rhinorrhea, nasal congestion, throat itching and cough symptoms improved more rapidly in Group 2 than in Group 1. Post-treatment nose itching and sneezing symptoms were significantly less in Group 2. The values of hematologic parameters were significantly reduced at the end of the 3rd week in both groups.

CONCLUSIONS

Our study is a first in investigating the combined use of large volume low pressure nasal saline and fluticasone propionate in acute pediatric rhinosinusitis, and the results reveal that the combination therapy was effective. Low pressure large volume nasal saline+fluticasone propionate combination can be employed as a new line of therapy for the treatment of pediatric acute rhinosinusitis, either by itself or combined with standard therapy.

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.

Inconclusive Evidence That Age Predicts a Prolonged or Chronic Course of Acute Rhinosinusitis in Adults

Objective

To review the evidence whether the risk for a prolonged or chronic course increases with age in adult patients with acute rhinosinusitis.

Data Sources

PubMed, EMBASE, and the Cochrane Library.

Review Methods

A comprehensive literature search was performed on March 24, 2013, and articles were screened and selected using predefined inclusion and exclusion criteria. Articles reporting studies on age as a predictor for the course in patients with acute rhinosinusitis were included. For included articles, the design of reported studies was assessed for directness of evidence and risk of bias. We aimed to extract hazard ratios for age as a continuous variable.

Results

Out of 13,382 unique publications, 3 articles with moderate risk of bias were included, with a maximum follow-up period of 30 days. The reported hazard ratios for recovery at 10, 15, and 30 days are 1.0 (95% confidence interval, 0.9-1.1) for age as a continuous variable, 0.86 (0.66-1.11) for age dichotomized at 38 years, and 0.58 (0.40-0.84) for age dichotomized for an increase with 20 years, respectively.

Conclusion and Recommendation

There is no evidence that age increases the risk for chronic rhinosinusitis in adult patients with acute rhinosinusitis. The literature is inconclusive that age increases the risk for a prolonged course of acute rhinosinusitis and, therefore, does not provide grounds for different management according to age of patients. As such, patients can be managed according to clinical practice guidelines with expectant observation and symptomatic treatment.

Inconclusive Evidence for Allergic Rhinitis to Predict a Prolonged or Chronic Course of Acute Rhinosinusitis

Objective

To systematically review the evidence on allergic rhinitis as a predictor for a prolonged or chronic course in adult patients with acute rhinosinusitis.

Data Sources

Pubmed, EMBASE, and the Cochrane library.

Review Methods

A systematic literature search was performed on March 15, 2013. During screening of title and abstract, 3 authors independently selected studies on allergic rhinitis as a predictor for the course of acute rhinosinusitis in adults. The reported study design was assessed for directness of evidence and risk of bias. We aimed to extract prior and posterior probabilities for a prolonged or chronic course of acute rhinosinusitis.

Results

Of 13,202 retrieved articles, 2 articles were eligible for study assessment. They provided a high directness of evidence but carried a high risk of bias. The studies showed an incidence of a prolonged and chronic course of, respectively, .19 (95% confidence interval [CI] .16-.23) and .05 (95% CI, .02-.13). In patients with allergic rhinitis, the incidence was .25 (95% CI, .18-.35) and .14 (95% CI, .04-.34), so the added value of allergic rhinitis to predict a prolonged course is 6% and to predict a chronic course 8%.

Conclusion and Recommendation

While the 2 included studies suggest that allergic rhinitis adds little to the prediction of a prolonged or chronic course in patients with acute rhinosinusitis, they carry a high risk of bias. As the available evidence does not provide grounds for different management of patients with and without allergic rhinitis, namely, according to clinical practice guidelines, both can be managed with expectant observation and symptomatic treatment.

Acute sinusitis in children: do antibiotics have any role?

Bacteria can be recovered from paranasal sinuses in the majority of patients given the diagnosis of acute bacterial sinusitis (ABS), and bacteriologic cure can be achieved with appropriate antibiotic treatment. The critical question is whether bacteriologic cure correlates with meaningful clinical endpoints such as clinical improvement, reduction in recurrent disease, or prevention of complications. Of the 4 pediatric placebo-controlled randomized clinical trials (PCRCTs), 2 suggest superiority of antibiotic treatment and 2 suggest lack of superiority. PCRCTs in adults are mixed as to clinical benefit. Pediatric and adult meta-analyses demonstrate modest benefit of antibiotic therapy and rates of spontaneous recovery without antibiotics of 60-65%. Although retrospective studies indicate that some patients who develop orbital or neurologic complications of sinusitis were pre-treated with antibiotic therapy, a low rate of complications precludes determination of whether antibiotic treatment prevents complications in some proportion of patients. Like the literature evidence, expert guideline recommendations are mixed. Although the evidence base is incomplete and conflicting, the limited data suggest that antibiotics probably do have a role in the treatment of pediatric ABS. The most compelling rationale is prevention of serious complications, but proof for this rationale is lacking.

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

[Endoscopic treatment of orbital cellulitis in pediatric patients: transethmoidal approach]

Orbital cellulitis is a septic process of the soft tissues behind the orbital septum and is the most frequent cause of the monolateral exophthalmos in pediatrics. Approximately 90% of the orbital cellulitis in pediatrics are associated to acute ethmoiditis. From the 01.01.2001 to 31.12.2010 we treated 36 patients, less than 18 years-old affected by Chandler stage II, III, or IV orbital cellulitis. The inflammation was resolved medically in 6 patients. In the 30 cases that showed no improvement in 48-72 h, an endoscopic drainage of the pus was performed by the transethmoidal route. In children, an adenoidectomy should be included, in order to eliminate eventual infections of this lymphatic organ. Endoscopic treatment has resulted in rapid resolution of disease without any complications. In addition, postoperative discomfort is minimal, with a rapid return to daily activities.

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.

Role of antibiotics in sinusitis

PURPOSE OF REVIEW

Sinusitis is a leading reason for outpatient antibiotic use, but symptoms are nonspecific. We review potential methods that might enhance the ability to appropriately prescribe antibiotics.

RECENT FINDINGS

The evidence base for antibiotic use in acute rhinosinusitis is strongest in studies with stringent entry criteria. In less restrictive studies antibiotics and placebo perform equally. Bacteria from nasopharyngeal swabs in adults correlate with sinus cultures. A recent study showed that antibiotics shortened the duration of acute rhinosinusitis (ARS) symptoms in children. Tellingly, over 2000 children with symptoms were screened to enroll less than 10% who fulfilled the study's stringent criteria. In chronic rhinosinusitis (CRS), two grade 1 studies on efficacy of long-term macrolide therapy showed conflicting results. Odontogenic sinusitis is underappreciated and frequently fails to grow on culture because of presumed difficulty in growing anaerobes.

SUMMARY

There is currently no grade 1 evidence to support antibiotic use in CRS; however, studies to date have not been conducted in patients with isolated purulent sinusitis. Future use of cultures to direct antibiotic therapy, such as nasopharyngeal swabs in adults with ARS or endoscopically guided cultures, may aid in targeting antibiotic therapy more effectively.

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.

Mometasone furoate nasal spray increases the number of minimal-symptom days in patients with acute rhinosinusitis

BACKGROUND

Acute rhinosinusitis (ARS) is triggered by viral or, uncommonly, bacterial infection, causing inflammatory symptoms for ≤12 weeks.

OBJECTIVE

To investigate effects of mometasone furoate nasal spray (MFNS) vs amoxicillin and placebo on minimal-symptom days.

METHODS

A double-blind, parallel-group, placebo- and active-controlled 15-day study randomly assigned patients 12 years of age or older to MFNS 200 μg twice daily, MFNS 200 μg once daily, amoxicillin 500 mg 3 times daily, or placebo. Patients had baseline rhinosinusitis major symptom score (MSS; combined rhinorrhea, postnasal drip, congestion, sinus headache, facial pain) of ≥5 and ≤12 (maximum: 15) for 7 to 28 days; scores were similar among groups. Minimal-symptom days and minimal-congestion days were defined post hoc by average am/pm MSS ≤4 and average AM/PM congestion ≤1.

RESULTS

MFNS twice daily (n = 234) showed more minimal-symptom days vs placebo (n = 246) (62.69% vs 50.33%; P < .0001) or amoxicillin (n = 248) (54.35%; P = .0040). The MFNS QD was associated with numerically more minimal-symptom days than amoxicillin or placebo (54.72%; P ≤ .8982). MFNS was associated with more minimal-congestion days than placebo (72.97%, 67.73%, and 56.67% for twice daily, once daily, and placebo; P < .0001, each vs placebo) and MFNS BID with more minimal-congestion days than amoxicillin (72.97% vs 64.15%; P = .0007). Median time to first minimal-symptom day sustained until study end was 8.5 days for MFNS BID vs. 11 for placebo (P = .0085).

CONCLUSION

MFNS 200 μg twice daily significantly increased minimal-symptom days vs amoxicillin or placebo in patients with ARS. Results of this intranasal corticosteroids (INS) therapy indicate it can improve outcomes and potentially reduce inappropriate antibiotic use.

"One-size-fits-all"? Optimizing treatment duration for bacterial infections

Historically, antibiotic treatment guidelines have aimed to maximize treatment efficacy and minimize toxicity, but have not considered the evolution of antibiotic resistance. Optimizing the duration and dosing of treatment to minimize the duration of symptomatic infection and selection pressure for resistance simultaneously has the potential to extend the useful therapeutic life of these valuable life-saving drugs without compromising the interests of individual patients.Here, using mathematical models, we explore the theoretical basis for shorter durations of treatment courses, including a range of ecological dynamics of bacteria that cause infections or colonize hosts as commensals. We find that immunity is an important mediating factor in determining the need for long duration of treatment. When immunity to infection is expected, shorter durations that reduce the selection for resistance without interfering with successful clinical outcome are likely to be supported. Adjusting drug treatment strategies to account for the impact of the differences in the ecological niche occupied by commensal flora relative to invasive bacteria could be effective in delaying the spread of bacterial resistance.

Management of rhinosinusitis in Dutch general practice

AIMS

To determine whether general practitioners (GPs) distinguish between the management of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS), especially with regard to prescription of antibiotics and nasal steroids.

METHODS

A questionnaire on the management of rhinosinusitis was sent to 1000 GPs in The Netherlands.

RESULTS

Ninety-six percent discriminated between ARS and CRS. However, the definition of ARS and CRS varied. The percentage of GPs prescribing antibiotics rose as rhinosinusitis severity increased. The prescription rate of nasal corticosteroids was highest for CRS (88.6%). Prescribing nasal corticosteroids in ARS was not very common.

CONCLUSIONS

Most GPs discriminate between ARS and CRS and 54% accepted (the EP3OS-defined) 12 weeks as the division between ARS and CRS. Antibiotics and nasal steroids are commonly used agents, but the management of rhinosinusitis is not always consistent with guidelines.

Management of acute rhinosinusitis in Danish general practice: a survey

PURPOSE

To evaluate whether the ongoing debate over diagnostic problems and treatment choices for acute rhinosinusitis has had any influence on the management of the disease.

METHODS

We randomly selected 300 Danish general practitioners (GPs) from the files of the Research Unit for General Practice at Aarhus University. Invitations to participate and a questionnaire were sent to the GPs by mail.

RESULTS

A total of 149 (49%) GPs answered the questionnaire. When asked about symptoms, the highest priority was given to sinus pain and signs of tenderness. The most frequent examinations were objective examination of the ear-nose-throat (ENT), palpation of the maxillofacial area, and C-reactive protein point-of-care testing (or CRP rapid test). Nearly all GPs prescribed local vasoconstrictors, and in 70% of cases, antibiotics were prescribed. Phenoxymethyl-penicillin was the preferred antibiotic. Use of the CRP rapid test, years in practice, or employment in an ENT department did not have a significant impact on the diagnostic certainty and antibiotic prescribing rate.

CONCLUSION

The clinical diagnoses are based on a few symptoms, signs, and the CRP rapid test. Other examinations, including imaging techniques, are seldom used. Phenoxymethylpenicillin is the preferred antibiotic, and the GPs' diagnostic certainty was 70%.

Value of routine sinus radiography in the diagnostic work-up of ill returned travelers: critical appraisal in a cohort of 765 travelers

BACKGROUND

Upper respiratory tract problems, eg, acute sinusitis are frequently occurring illnesses in returned travelers. The most accurate and cost-effective method for diagnosing these upper respiratory tract illnesses in hospital-based settings remains an area of uncertainty. In the present retrospective cohort study, the usefulness of routine sinus radiography in the diagnostic work-up of ill returned travelers was evaluated.

METHODS

This study was done at the Institute for Tropical Diseases in Rotterdam, and included all returned travelers who were ill with symptoms lasting less than one month in the period 2007-2009 and had sinus radiography on admission. Traveler demographic (including travel history), clinical, and laboratory data were collected on admission, and sinus radiography findings evaluated for their diagnostic power to predict sinusitis.

RESULTS

One hundred and sixty-five (22%) of 765 ill returned travelers had abnormal sinus radiography; more than half of the abnormal radiographic findings comprised mucosal membrane thickening of the sinuses. More than half of the travelers with abnormal sinus radiography had no upper respiratory tract symptoms at admission, which raises doubt about the clinical relevance of abnormal radiographic findings. Travelers with abnormal sinus radiography were more likely to receive nasal decongestants (relative risk 18.2, confidence interval 9.4-35.1) but not antibiotics.

CONCLUSION

The results of the present study indicate that there is no additional value for routine sinus radiography in the diagnostic work-up of ill returned travelers.

Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines

Rhinosinusitis (RS) affects approximately 1 in 7 adults in the United States, and its effect on quality of life, productivity, and finances is substantial. During the past 10 years, several expert panels from authoritative bodies have published evidence-based guidelines for the diagnosis and management of RS and its subtypes, including acute viral RS, acute bacterial RS, chronic RS (CRS) without nasal polyposis, CRS with nasal polyposis, and allergic fungal RS. This review examines and compares the recommendations of the Rhinosinusitis Initiative, the Joint Task Force on Practice Parameters, the Clinical Practice Guideline: Adult Sinusitis, the European Position Paper on Rhinosinusitis and Nasal Polyps 2007, and the British Society for Allergy and Clinical Immunology. Points of consensus and divergent opinions expressed in these guidelines regarding classification, diagnosis, and management of adults with acute RS (ARS) and CRS and their various subtypes are highlighted for the practicing clinician. Key points of agreement regarding therapy in the guidelines for ARS include the efficacy of symptomatic treatment, such as intranasal corticosteroids, and the importance of reducing the unnecessary use of antibiotics in ARS; however, guidelines do not agree precisely regarding when antibiotics should be considered as a reasonable treatment strategy. Although the guidelines diverge markedly on the management of CRS, the diagnostic utility of nasal airway examination is acknowledged by all. Important and relevant data from MEDLINE-indexed articles published since the most recent guidelines were issued are also considered, and needs for future research are discussed.

Azithromycin extended release vs amoxicillin/clavulanate: symptom resolution in acute sinusitis

OBJECTIVE

The aim of the study was to compare early symptom resolution with a single 2-g dose of azithromycin extended release or 10 days of amoxicillin/clavulanate 875 mg/125 mg every 12 hours in patients with acute sinusitis.

MATERIALS AND METHODS

This was a prospective, randomized, open-label, observational study to mimic "real-world" conditions, including patients with symptoms of acute bacterial sinusitis lasting between 7 and 30 days. Key symptoms were assessed twice daily by patient diary, and patients were interviewed by telephone at 12 and 28 days. The primary end point was symptom resolution at 5 days, defined as reporting "no problem" with at least 3 of 4 diary symptoms in 2 consecutive measures in the per-protocol population. Secondary end points included additional antibiotic use, sinusitis-related quality of life, and treatment satisfaction.

RESULTS

Three hundred seventy-eight patients were randomized to a single dose of azithromycin extended release and 371 to 10 days of amoxicillin/clavulanate. In the per-protocol population at day 5, 70/236 patients (29.7%) in the azithromycin extended release arm and 45/238 patients (18.9%) in the amoxicillin/clavulanate arm had resolution of symptoms (difference = 10.8%; 95% confidence interval [CI], 3.1-18.4%). By day 28, 26/236 patients (11.0%) in the azithromycin extended release arm and 27/238 patients (11.3%) in the amoxicillin/clavulanate arm had used additional antibiotics (difference = -0.4%; 95% CI: -6.1% to 5.3%). Additional physician visits, quality of life, and overall satisfaction were similar between groups.

CONCLUSIONS

More patients randomized to azithromycin extended release experienced symptom resolution at day 5 than those randomized to amoxicillin/clavulanate, without experiencing differences in second antibiotic use at 28 days.

Upper Respiratory Infections and Acute Bronchitis

Upper respiratory infections include the following: uncomplicated upper respiratory infections also known as the “common cold,” acute otitis media, pharyngitis/tonsillitis, and acute sinusitis. These conditions, along with acute bronchitis, are very common illnesses that are commonly seen in outpatient settings and are widely treated with antibiotics. In fact, these conditions are the primary indications for outpatient antibiotic prescriptions. These conditions tend to have overlapping clinical characteristics yet evidence regarding the utility of antimicrobial treatments varies across conditions.

Chronic rhinosinusitis gives a ninefold increased risk of chronic headache. The Akershus study of chronic headache

We studied the association of chronic headache and chronic rhinosinusitis in 30 000 persons aged 30–44 years from the general population. They received a mailed questionnaire. Those with possible chronic headache were interviewed by neurological residents. The criteria of the American Academy of Otolaryngology—Head and Neck Surgery were applied to diagnose headache attributed to chronic rhinosinusitis (HACRS), otherwise the International Classification of Headache Disorders was used. The questionnaire response rate was 71%, and the participation rate of the interview was 74%. Compared with the general population, persons with chronic rhinosinusitis have an at least ninefold increased risk of having chronic headache. A 3-year follow-up showed that HACRS symptoms were significantly improved after treatment with nasal surgery, nasal corticosteroids, discontinuation of overused headache medications and discontinuation of nasal decongestants or unspecified reasons. Chronic rhinosinusitis is significantly associated with chronic headache, and HACRS is likely to be a distinct type of headache.

Economic evaluation of Sinfrontal in the treatment of acute maxillary sinusitis in adults

Sinfrontal, a complex homeopathic medication, is popular in Germany for the treatment of ear, nose and throat and respiratory tract infections. Unlike many other homeopathic or herbal medications, the efficacy and safety of Sinfrontal has been demonstrated in a number of clinical studies of patients with sinusitis. To assess the cost effectiveness of Sinfrontal versus placebo in the treatment of adults with acute maxillary sinusitis (AMS) in Germany. A secondary objective was to assess the cost effectiveness of Sinfrontal versus standard treatment with antibacterials. Sinfrontal was compared with placebo in a cost-utility analysis based on data from a randomized controlled clinical trial over 3 weeks (Sinfrontal group: n = 57; placebo group: n = 56). Trial data were analysed from a societal perspective; resource use was valued with German unit costs for 2005. In a secondary analysis, the longer-term cost utility of Sinfrontal versus placebo was estimated over a total of 11 weeks based on an 8-week post-treatment observational phase. In addition, the cost effectiveness of Sinfrontal versus antibacterials was determined based on an indirect comparison of placebo-controlled trials. Sinfrontal led to incremental savings of euro 275 (95% CI 433, 103) per patient compared with placebo over 22 days, essentially due to the markedly reduced absenteeism from work (7.83 vs 12.9 workdays). Incremental utility amounted to 0.0087 QALYs (95% CI 0.0052, 0.0123), or 3.2 quality-adjusted life-days (QALDs). Bootstrapping showed that these findings were significant, with Sinfrontal being dominant in 99.9% of simulations. The results were robust to a number of sensitivity analyses. In the secondary analysis, Sinfrontal led to incremental cost savings of euro 511 and utility gains of 0.015 QALYs or 5.4 QALDs compared with placebo. Compared with antibacterials, Sinfrontal had a significantly higher cure rate (11% vs 59%; p < 0.001) at similar or lower costs. The results of this economic evaluation indicate that Sinfrontal may be a cost-effective treatment for AMS in adults.

Intranasal corticosteroids in the treatment of acute rhinosinusitis

Acute rhinosinusitis (ARS) is one of the most frequent diagnoses in clinical practice. Common symptoms include anterior and/or posterior nasal drainage, nasal obstruction, and facial pain, pressure, or sensation of fullness. ARS etiology is more often viral than bacterial, and infection-initiated inflammation is the primary pathophysiologic mechanism responsible for symptoms. Because ARS is usually a self-limited process, the primary goal of treatment is symptom relief, which can be more effectively achieved by targeting the underlying inflammation. Intranasal steroids (INS) have been shown to reduce components of respiratory inflammation and increase symptom relief for ARS when used alone or combined with antibiotics. Based on current evidence in support of INS therapy, the European Position Paper on Rhinosinusitis and Nasal Polyps 2007 guidelines and a recent Cochrane meta-analysis recommend using INS in the treatment of ARS, both as monotherapy and as an adjunct to antibiotics.

Antibiotics for acute maxillary sinusitis

BACKGROUND

Expert opinions vary on the appropriate role of antibiotics for sinusitis, one of the most commonly diagnosed conditions among adults in ambulatory care.

OBJECTIVES

We examined whether antibiotics are effective in treating acute sinusitis, and if so, which antibiotic classes are the most effective.

SEARCH STRATEGY

We 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).

SELECTION CRITERIA

Randomized 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, whether or not confirmed by radiography or bacterial culture.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened search results, extracted data and quality assessed trials. Risk ratios (RR) were calculated for differences in the intervention and control groups to see whether or not the treatment was a failure. In meta-analysing the placebo-controlled studies, the data across antibiotic classes were combined. Primary outcomes were the clinical failure rates at 7 to 15 days and 16 to 60 days follow up.

MAIN RESULTS

Fifty-seven studies were included in the review; six placebo-controlled studies and 51 studies comparing different classes of antibiotics. Five studies involving 631 participants provided data for comparison of antibiotics to placebo, when clinical failure was defined as a lack of cure or improvement at 7 to 15 days follow up. These studies found a slight statistical difference in favor of antibiotics, compared to placebo, with a pooled RR of 0.66 (95% confidence interval (CI) 0.44 to 0.98). However, the clinical significance of the result is equivocal, also considering that cure or improvement rate was high in both the placebo group (80%) and the antibiotic group (90%). Based on six studies, when clinical failure was defined as a lack of total cure, there was significant difference in favor of antibiotics compared to placebo with a pooled RR of 0.74 (95% CI 0.65 to 0.84) at 7 to 15 days follow up. None of the antibiotic preparations was superior to each other.

AUTHORS' CONCLUSIONS

Antibiotics have a small treatment effect in patients with uncomplicated acute sinusitis in a primary care setting with symptoms for more than seven days. 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.

Clinical practice guideline: adult sinusitis

OBJECTIVE

This guideline provides evidence-based recommendations on managing sinusitis, defined as symptomatic inflammation of the paranasal sinuses. Sinusitis affects 1 in 7 adults in the United States, resulting in about 31 million individuals diagnosed each year. Since sinusitis almost always involves the nasal cavity, the term rhinosinusitis is preferred. The guideline target patient is aged 18 years or older with uncomplicated rhinosinusitis, evaluated in any setting in which an adult with rhinosinusitis would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with sinusitis.

PURPOSE

The primary purpose of this guideline is to improve diagnostic accuracy for adult rhinosinusitis, reduce inappropriate antibiotic use, reduce inappropriate use of radiographic imaging, and promote appropriate use of ancillary tests that include nasal endoscopy, computed tomography, and testing for allergy and immune function. In creating this guideline the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of allergy, emergency medicine, family medicine, health insurance, immunology, infectious disease, internal medicine, medical informatics, nursing, otolaryngology-head and neck surgery, pulmonology, and radiology.

RESULTS

The panel made strong recommendations that 1) clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions, and a clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening), and 2) the management of ABRS should include an assessment of pain, with analgesic treatment based on the severity of pain. The panel made a recommendation against radiographic imaging for patients who meet diagnostic criteria for acute rhinosinusitis, unless a complication or alternative diagnosis is suspected. The panel made recommendations that 1) if a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin as first-line therapy for most adults, 2) if the patient worsens or fails to improve with the initial management option by 7 days, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications, 3) clinicians should distinguish chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis from isolated episodes of ABRS and other causes of sinonasal symptoms, 4) clinicians should assess the patient with CRS or recurrent acute rhinosinusitis for factors that modify management, such as allergic rhinitis, cystic fibrosis, immunocompromised state, ciliary dyskinesia, and anatomic variation, 5) the clinician should corroborate a diagnosis and/or investigate for underlying causes of CRS and recurrent acute rhinosinusitis, 6) the clinician should obtain computed tomography of the paranasal sinuses in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 7) clinicians should educate/counsel patients with CRS or recurrent acute rhinosinusitis regarding control measures. The panel offered as options that 1) clinicians may prescribe symptomatic relief in managing viral rhinosinusitis, 2) clinicians may prescribe symptomatic relief in managing ABRS, 3) observation without use of antibiotics is an option for selected adults with uncomplicated ABRS who have mild illness (mild pain and temperature <38.3 degrees C or 101 degrees F) and assurance of follow-up, 4) the clinician may obtain nasal endoscopy in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 5) the clinician may obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent acute rhinosinusitis.

DISCLAIMER

This clinical practice guideline is not intended as a sole source of guidance for managing adults with rhinosinusitis. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.