February 14th, 2012

Is It Time To Stop Treating Acute Sinusitis?

From the pages of JAMA comes this startling clinical trial:

A randomized, placebo-controlled trial of adults with uncomplicated, acute rhinosinusitis [who] were recruited from 10 community practices in Missouri between November 1, 2006, and May 1, 2009 … [Subjects received a] ten-day course of either amoxicillin (1500 mg/d) or placebo administered in 3 doses per day … 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).

To be fair, I did leave out that outcomes favored the amoxicillin group at day 7. And I also left out that the validated instrument they used to gauge symptoms was called the “Sinonasal Outcome Test-16”, or “SNOT-16”


But still — I’m willing to wager good money that if you asked 100 primary care providers, ENT specialists, ID doctors, and patients whether they thought antibiotics helped relieve symptoms of acute sinusitis, 90% would answer “yes.”

And 99% would would want it for themselves.

Critics of this study might quibble about the inclusion criteria, or the fairly large number of screened study subjects who were not enrolled, or the selection of amoxicillin over amoxicillin-clavulanate. What, no Moraxella catarrhalis coverage?

Regardless, this trials reminds us that, even though it’s hard to believe, the human species did survive many eons before the discovery of antibiotics in the 20th century, and that furthermore, most of the common community-acquired infections resolve spontaneously.

Time will tell whether the results from the study will influence practice guidelines, patient perception, and — most importantly — clinical practice.

4 Responses to “Is It Time To Stop Treating Acute Sinusitis?”

  1. Robert M Wein, MD says:

    When I take Ceftin 500 bid for 10 days for what I feel is sinusitis (I have had sinus surgery and have significant allergies) I find on day 4 or 5 that I have a tremendous production of muco=purulent material upon nasal irrigation and I start to feel much better. This happens about 1-2 times a year — usually when allergy season is in “bloom”.

  2. anonydoc says:

    cefuroxim lacks bioavailability, which is why I wouldn’t use it orally at all. neither in myself nor in patients.

  3. Carol Vassar, MD says:

    Neither the Journal Watch article nor the JAMA abstract indicated how long these patients had had symptoms, 3 days, 7 days or two weeks. Some study I read years ago, many years ago, did sinus CT’s on patients with acute URI symptoms. I believe that the result of the study was that 60% of viral URI patients had sinusitis on CT. But these patients cleared their apparently viral sinusitis. I just checked the paper JAMA to find that the inclusion criteria for duration of symptoms was >7 and 14 days.

  4. Sarah Smithson, MD says:

    Dr. Sax, I would love to hear your take on the IDSA clinical practice guidelines for managing acute bacterial sinusitis referred to in today’s Physician’s First Watch (http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full).

    Reading it made me think of your comments about the JAMA study above, and it reinforced with me why it is so hard for many providers to change their clinical practices. We see so much conflicting information.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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