Rx for Sinus Patients Wait

Popping pills is no help, for antibiotics do not relieve most infections, says study

If you8217;re one of the millions who get a sinus infection each year, experts agree: You8217;re being prescribed antibiotics too often. Now some are saying you shouldn8217;t get them at all.

Antibiotics should never be prescribed for otherwise healthy adults with sinusitis, an analysis of a collection of studies concludes in The Lancet. Belgian and Swiss researchers who reviewed data from nine clinical trials involving more than 2,500 people with sinus infections found that the vast majority who received antibiotics didn8217;t need them. That8217;s because while 80 per cent of patients diagnosed with an acute sinus infection are prescribed antibiotics, only 5 to 10 per cent of such infections are bacterial and respond to the drugs. But doctors often have a hard time distinguishing between viral and bacterial strains.

Over-prescription of antibiotics for a host of medical conditions has led to widespread antibiotic resistance 8212; meaning doctors have fewer drugs effective against many bacterial infections.

But the Lancet study8217;s conclusions conflict with sinus infection guidelines published last year by the American Academy of Otolaryngology in Head and Neck Surgery. Those guidelines recommend antibiotics usually amoxicillin if symptoms last more than 10 days. And some experts are calling the study8217;s advice too extreme.

8220;There8217;s no question that antibiotic resistance is a huge issue when it comes to treating sinusitis,8221; said Richard Rosenfeld, chairman of otolaryngology at Long Island College Hospital in New York and the head of the task force that issued the guidelines. 8220;After all, about 20 per cent of all antibiotics prescribed for adults are given to treat sinus infections, and at least some of that is unnecessary.8221;

But Rosenfeld and others said the Lancet analysis was not a sufficient basis for changing clinical practice because it was a meta-analysis, not a randomised trial comparing patients treated with and without antibiotics.

What8217;s more, said Rosenfeld, the analysis did not include patients diagnosed on the basis of CT scans, nasal cultures or other sophisticated tests.

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8220;That means that patients most likely to have a bacterial sinus infection would have been excluded from the study,8221; said Rosenfeld.

Sinuses are hollow spaces behind the nose, cheeks, forehead and eyes that are lined with mucous membranes.

These membranes can become infected when a virus in the nose travels to the sinuses. Nose secretions caused by allergies, colds, cigarette smoke and environmental irritants can also travel to the sinuses and become trapped, causing a bacterial infection.

In either case, said Stanley Chia, a staff otolaryngologist at the Washington Hospital Center, symptoms may include low-grade fever, pain and pressure behind the nose, headaches and a runny nose, sometimes with a coloured discharge.

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An infection that lasts up to four weeks is defined as an acute infection; one that lasts more than 12 weeks is considered chronic. An antibiotic prescription is warranted for sinusitis patients with chronic health problems such as heart disease or diabetes, which could be exacerbated by a bacterial infection, said Rodney Taylor, an associate professor of otolaryngology at the University of Maryland Medical Center.

Antibiotics can also curtail rare spreads of the infection to the eyes and even brain, said Chia. According to the Centers for Disease Control and Prevention, the number of bacteria resistant to antibiotics has increased in the past decade, and many major bacterial infections 8212; including tuberculosis, some pneumonias and a growing number of hospital-acquired illnesses 8212; are becoming resistant to common antibiotics, such as amoxicillin, and even last-resort ones like methicillin and vancomycin.

Better treatment choices, according to the Academy, are cleansing with a saline solution or using a nonprescription decongestant.

But a patient with a pounding headache from sinusitis typically is more focused on relief than the state of world microbials. The challenge is to figure out when an infection is bacterial and when not.

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While otolaryngologists can rely on sophisticated tools such as endoscopes 8212; lighted tubes that can see inside nasal passages and detect pus in sinuses, a sign that an antibiotic may be needed 8212; primary care doctors usually rely on nose secretions and a patient8217;s report, said Taylor. And while yellow or green mucus was once regarded as a sure sign of bacterial infection, doctors now know that this is not necessarily the case, leaving generalists without a clear sign of when to prescribe drugs and when not.

The Academy guidelines suggest that doctors consider prescribing antibiotics usually amoxicillin if symptoms 8212; including colored nasal discharge 8212; persist beyond 10 days, or improve within a 10-day period and then worsen.