He stressed that managing patient expectations is an important part of antibiotic therapy for sinusitis. For example, physicians should inform their patients that significant inflammation typically accompanies sinusitis. Therefore, they may not feel completely better with antibiotics alone. If the patient is using amoxicillin clavunate plus amoxicillin, Dr. Anon also prescribes a week of treatment with prednisone to address the inflammation.
Explore This Issue
October 2008Treatment of inflammation is more complicated when the patient is treated with fluoroquinolones, because they have been associated with rupture of the Achilles tendon. Therefore the Food and Drug Administration (FDA) has issued a black box warning for the drug.4 Patients on fluoroquinolones should not receive concomitant corticosteroids, he said. To minimize the risk of tendon rupture, Dr. Anon has recommended magnesium supplements to patients on fluoroquinolones.
A Challenging Balance
The issues to consider are the severity of the infection and the patient’s thoughts regarding the benefits of antibiotic treatment compared to the risk of adverse events, said Dr. Rosenfeld.
To gauge the severity, the physician must consider both objective and subjective information. The infection is considered mild if the patient’s temperature is less than 101° F and pain is not severe. With mild sinus infections, we know from randomized trials that 73 percent of patients improve on their own in seven to 12 days whether they receive the antibiotic or the placebo. If you treat such infections with an antibiotic, you increase the resolution 14 percent-from 73 percent to 87 percent.
We have shown in several studies that levofloxacin will sterilize Haemophilus influenzae with one 750-mg dose. Streptococcus pneumoniae requires about three days of treatment before the organism has been eradicated.-Jack B. Anon, MD
The question to ask the individual patient with mild sinusitis is: Are the treatment and the risk of adverse events worth the extra 14%? The adverse effects are primarily gastrointestinal upset, rashes, and allergic reactions, Dr. Rosenfeld said. More women than men get sinusitis; therefore, another potential adverse effect is yeast vaginitis. The physician needs to know whether, for a patient with mild sinusitis, these risks are worth the potential for improving three to four days faster.
If the patient is relatively comfortable despite the sinusitis, it’s very reasonable to watch and wait and see if the sinusitis resolves, he said. He added that the patient may have some professional or personal issues that would make a stronger case for antibiotic treatment. For example, if the patient has an airplane trip coming up or is a professional singer and needs to clear the sinuses as quickly as possible to be able to perform, antibiotic treatment would have some appeal. This needs to be a shared decision with the patient, Dr. Rosenfeld said.