The Pharmaceutical Journal
Vol 280 No 7494 p328
22 March 2008

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Lancet study suggests antibiotics not justified for sinusitis even if symptoms exceed a week

Antibiotics offer little benefit for patients with sinusitis, according to a study in The Lancet (2008;371:908), even those with symptoms lasting more than a week.

Researchers conducted a meta-analysis of nine trials involving 2,547 adults with acute sinusitis-like complaints who were randomly assigned to receive antibiotic or placebo.

They found that 15 patients would need to be treated to cure one patient. This number needed to treat dropped to eight for patients with a purulent discharge from the throat.

The results suggest that most common signs and symptoms do not help distinguish a bacterial from a viral infection, say the researchers. In particular, patient-reported symptoms, such as a previous common cold or facial pain, do not seem as reliable as some guidelines suggest, they add.

“Common clinical signs and symptoms cannot identify a subgroup for which treatment is clearly justified, given the cost, adverse events and bacterial resistance associated with antibiotic use,” the researchers say.

Patients who were older, those who reported symptoms for longer or reported more severe symptoms were no more likely to benefit from antibiotics than other patients. This suggests that antibiotics are not justified even if patients report symptoms for longer than seven to 10 days, contrary to some guidelines, say the researchers.

The researchers warn that their results do not apply to children or to those with suppressed immune systems. However, they say: “[The results] should reassure physicians that only watchful waiting and symptomatic relief are warranted for almost all adult patients with acute rhinosinusitis-like complaints.”

The authors of an accompanying editorial point out that the implications of the study are not clear cut because of well known problems with meta-analyses. They add: “Many patients with obvious viral illness who had no chance of benefiting from antibiotic treatment were included in the meta-analysis, which might make the analysis underpowered to detect meaningful difference.”

The National Institute for Health and Clinical Excellence published draft guidance on prescribing of antibiotics for self-limiting respiratory tract infections, including sinusitis, last week. It recommended that antibiotics should normally not be prescribed, or a delayed prescription should be issued so that patients can obtain antibiotics if their symptoms do not resolve.