Amoxicillin for Acute Rhinosinusitis

Abstract

Context Evidence to support antibiotic treatment for acute rhinosinusitis is scant, 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 Randomized placebo-controlled trial Participants and Setting Adults with uncomplicated, acute rhinosinusitis were recruited from 10 community practices in Missouri between November 1st 2006 and May 1st 2009 Interventions Ten-day course of either amoxicillin (1500mg/day) or placebo administered in three doses/day. All patients received a 5-7-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 the disease-specific quality of life after 3–4 days of treatment assessed with the SNOT-16 (minimally important difference 0.5 on 0 to 3 scale). Secondary outcomes included the patients' retrospective assessment of change in sinus symptoms and functional status, recurrence or relapse, satisfaction with and adverse effects of treatment. Outcomes were assessed by telephone interview at Days 3, 7, 10 and 28. Results 166 adults (36% male, 78% Caucasian) were randomized to amoxicillin (85) or placebo (81); 92% concurrently used ≥1 symptomatic treatment (amoxicillin, 94%, placebo 90%, p=0.34). The mean change in SNOT-16 scores was not significantly different between groups on Day 3 (mean difference between groups 0.03, 95% CI −0.12 to 0.19) and Day 10, but differed at Day 7 favoring amoxicillin (mean difference between groups 0.19, 95% CI 0.024 to 0.35). At Day 7 more participants treated with amoxicillin reported symptom improvement (74% vs. 56%, p=0.0205; NNT = 6, 95% CI 3 to 34), with no difference at Day-3 or Day-10. 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.

Variations in Antibiotic Prescribing of Acute Rhinosinusitis in United States Ambulatory Settings

“…3 In a Cochrane review, there was 80% improvement rate in placebo arms compared with 90% improvement rates in antibiotic arms, 4 demonstrating that a large percentage of ARS resolves spontaneously. Meta-analyses comparing antibiotic treatment with placebo show only a modest improvement rate of 7% to 14% with antibiotics 5 and that 15 patients with rhinosinusitis-like complaints would have to be given antibiotics before an additional patient was cured.…”

“…2 A growing body of evidence suggests that antibiotics do not confer a distinct clinical advantage in the vast majority of ARS cases, 1,3–5 and antibiotics are not recommended for most patients with mild cases of uncomplicated acute rhinosinusitis according to major consensus guidelines. 6–12 However, previous studies show that antibiotics are prescribed in 82% to 88% of patient visits for acute sinusitis, suggesting a substantial degree of antibiotic use.…”

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

“…Despite the fact that only a small percentage of viral upper respiratory tract infections (URTIs) are complicated by bacterial infection, more than 80% of patients with symptoms of rhinosinusitis are prescribed antibiotics [2]. Several studies have shown that antibiotics provide few if any benefits in patients that are classified clinically with the diagnosis acute rhinosinusitis [3,4]. …”

Trends and Seasonal Variation in Outpatient Antibiotic Prescription Rates in the United States, 2006 to 2010

“…Despite this large volume of use, surprisingly little is known about patterns of use. Since greater than 60% of all antibiotic expenditures are in the outpatient setting (18) and a significant percentage of prescribing is inappropriate (9,14,20,21), it is important to identify when and where to target interventions to reduce use in ambulatory care. The purpose of this study was to describe trends and seasonal variations in dispensed outpatient antibiotic prescriptions in the United States over a 5-year period to identify opportunities for public health intervention where seasonal peaks may represent increases in inappropriate use.…”