Antibiotics for acute maxillary sinusitis

Ahovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, Liira H, Williams Jr JW, Mäkelä M

Published Online:

March 16, 2011

Sinusitis is one of the most common reasons for visiting a doctor, with 20 million visits for this condition every year in the USA alone. There are four pairs of sinuses linked to the bony structures around the nose: the maxillary, frontal, ethmoidal and sphenoidal sinuses. In sinusitis, these membrane-lined air spaces become infected, which causes pain and discharge from the nose. Treatment options include decongestants, steroid drops or sprays, mucus-clearing drugs (mucolytics), antihistamines and antibiotics, and/or sinus puncture and lavage.

In most cases sinusitis accompanies viral cold infections where antibiotics are ineffective, but the few cases that have additional bacterial infections (one or two of every 100 patients with sinus symptoms) could benefit. Unfortunately it is difficult to distinguish between those who have bacterial infections and those who have not but it is important to avoid unnecessary use of antibiotics and thereby limit the potential for antibiotic resistance.

This systematic review drew together data from 59 separate studies that used a variety of antibiotics for simple maxillary sinus infection (i.e. non-complicated acute sinusitis in a person with a healthy immune system) in primary care settings. Six of the studies (747 participants) compared antibiotics to placebo and found that most of the participants got better within two weeks, regardless of whether they received the antibiotic or not. When antibiotics were given they somewhat speeded up recovery from sinusitis symptoms. In the remaining 53 studies comparing different antibiotics, none of the antibiotics were found to be superior to the others.

The small benefit gained by antibiotics may be overridden by the negative effects of the drugs. In addition to patient-related adverse effects (like skin rash and gastrointestinal problems, for example, diarrhoea, abdominal pain and vomiting), side effects include the risk of increased resistance to antibiotics among community-acquired pathogens.

This review found that antibiotics help some people a bit, but do not make a major difference to most people with acute maxillary sinusitis in primary care settings.

Abstract (click to read)

Background:

The role of antibiotics for sinusitis, one of the most common diagnoses among adults in ambulatory care, is controversial.

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 CENTRAL (2010, Issue 1) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to March Week 2, 2010) and EMBASE (1974 to March 2010).

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:

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

Main results:

We included 59 studies in the review; six placebo-controlled studies (five of them conducted in primary care) and 53 studies comparing different classes of antibiotics. Five of the placebo-controlled studies (four low and one moderate/unclear risk of bias) involving 631 participants reported clinical failure rates (lack of cure or improvement) at seven to 15 days follow up. For participants with symptoms lasting at least seven days, antibiotics decreased the risk of clinical failure (pooled RR of 0.66, 95% confidence interval (CI) 0.44 to 0.98). However, the clinical benefit was small; cure or improvement rate was high in both the placebo group (80%) and the antibiotic group (90%). When clinical failure was defined as a lack of total cure (n = six studies), results were similar: antibiotics decreased the risk of failure (pooled RR of 0.74, 95% CI 0.65 to 0.84) at seven to 15 days follow up. In head-to-head comparisons, none of the antibiotic preparations was superior to the others.

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, 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 level.

This record should be cited as:

Ahovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, Liira H, Williams Jr JW, Mäkelä M. Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000243. DOI: 10.1002/14651858.CD000243.pub2

Assessed as up to date:

March 19, 2010

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Primary Review Group:

Acute Respiratory Infections Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective are antibiotics in treating acute sinusitis?

Bottom line:

In a primary care setting, antibiotics have a small treatment effect in patients with uncomplicated acute sinusitis with symptoms for more than 7 days (average improvement rate of 90% in antibiotic groups and 80% in the control groups; NNT* 10).The review contains trials of treatment for clinically diagnosed acute sinusitis, whether or not confirmed by radiography or bacterial culture. Drug therapies reviewed were antibiotic versus control or comparisons between different antibiotic classes. None of the antibiotic preparations (amoxycillin, amoxycillin-clavulanate, azithromycin, cephalosporins, faropenem, fluoroquinolones, macrolides, oxymetazoline, streptogramin and tetracyclines) was superior to each other. *NNT = number needed to treat to benefit one individual.

Caveat:

Eighty per cent of participants treated without antibiotics improved within 2 weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual level (diarrhoea, abdominal pain, vomiting and skin rashes) and general population level (antibiotic resistance).

Context:

Sinusitis accounts for 15–21% of all antibiotic prescriptions for adults in outpatient care. Treatment options include antibiotics, decongestants, steroid drops or sprays, mucolytics, antihistamines, or sinus puncture and lavage.

Cochrane Systematic Review:

Ahovuo-Saloranta A et al. Antibiotics for acute maxillary sinusitis. Cochrane Reviews 2008, Issue 2. Article No. CD000243. DOI: 10.1002/14651858. CD000243. pub2. This review contains 57 trials involving 18,962 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Infectious disease > Respiratory infections > Sinusitis

Lungs & airways > Respiratory infections > Sinusitis

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Antibiotics for acute maxillary sinusitis

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