Antibiotics could be useless in 95% of cases of acute sinusitis

1 in 5 antibiotic prescriptions given to US adults is for treatment of sinusitis, but in most cases, the medication does not provide symptom relief. Almost 90% of patients who go to the physician’s office with sinusitis will walk out with a prescription for antibiotics.

This randomized, placebo-controlled trial included 166 adults with uncomplicated, acute rhinosinusitis from 10 community practices in Missouri over 3 years (JAMA, 2012).

10-day course of either amoxicillin (1500 mg/d) or placebo administered in 3 doses per day. Editor's note: the amoxicillin dose is low. Epocrates quotes amoxicillin dose of 1 g PO q8h x10 days, Max: 4 g/day; Alt: 1.5-4 g/day PO div q6-8h.

Here is the JAMA video which includes a brief interview with one of the authors:



The primary outcome was improvement in disease-specific quality of life after 3-4 days of treatment assessed with the Sinonasal Outcome Test-16 (Snot-16). Editor's note: All diagnoses were based on symptoms, no CT imaging was done. It is not even clear if the patients actuall had sinusitis or not.

Among patients with acute rhinosinusitis, a 10-day course of amoxicillin compared with placebo did not reduce symptoms at day 3 or day 10 of treatment.

In most cases, sinusitis develops after a cold, and this viral infection will be complicated by a bacterial infection - which can respond to antibiotic therapy - in less than 5% of cases. So, that means that antibiotics could be useless in 95% of cases of acute sinusitis.

However, considering the limitations of this study (low antibiotic dose, no imaging), I would await the results of a more rigorous trial before making significant changes to the current standard of care.

References:

Amoxicillin for Acute Rhinosinusitis. A Randomized Controlled Trial. JAMA. 2012;307(7):685-692. doi: 10.1001/jama.2012.138

Author Insights: Treatment of Acute Sinusitis With Antibiotics Often Futile. JAMA Blog.

Comments from Twitter:

CERTIFIED Allergy @allergysa: Disappointed more well-designed studies haven't been done. But even air-fluid levels won't necessarily point to BACTERIAL infection

Matthew Bowdish MD @MatthewBowdish: Lots of limitations RT @Allergy "Antibiotics No Help for Sinusitis" - however, read last few paragraphs for limitations http://goo.gl/WW7yC

Carlos Mijares @carlosmixares: Agreed in viral rhinosinusitis!

Murfomurf @Murfomurf: Any antibiotics, when it's an infection, NOT just allergy??