Evidence-Based Sinusitis

The infectious disease group guidelines, however, discuss the lack of stringent criteria used in the studies. Most of the clinical trials comparing

antibiotics to placebo enrolled patients with seven to 10 days of symptoms. Therefore, as the IDSA reasoning goes, it’s likely that a good proportion of participants in the clinical trials had viral sinusitis (even at 10 days, the percentage of viral illness in adults may be 40 percent), which would not respond to antibiotics, would resolve spontaneously and would muddy the data. Therefore, the IDSA guidelines state unequivocally that once bacterial involvement is diagnosed, withholding or delaying antibiotics is not recommended.

Other reviews of the clinical trial data have concluded that watchful waiting is warranted for most patients, even after 10 days of symptoms. An international team did a meta-analysis of nine clinical trials in which participants were randomly assigned to antibiotic treatment or placebo. Importantly, the team didn’t just average aggregate data but, rather, obtained individual subject data from the trials with the specific aim to identify particular clinical signs or symptoms that predicted a response to antibiotic treatment (Lancet. 2008;371(9616):908-914).

Not only did the group conclude that antibiotics offer little benefit for adults with acute sinusitis, but also, the meta-analysis authors wrote: “Antibiotics are not justified even if a patient reports symptoms for longer than seven to 10 days.”

It’s one thing to analyze the studies and make recommendations, however, and another thing entirely to be in the primary care office. “No one waits ten days—not the patients, not the doctors,” said Dan Merenstein, MD, coauthor of the Lancet study and assistant professor and director of research programs in the department of family medicine at Georgetown University School of Medicine in Washington, D.C. He quoted the statistic that more than 80 percent of people who seek treatment get antibiotics (Fam Med. 2006;38:349-354).

“It is hard to change behavior,” said Stephen Smith, MD, MPH, professor emeritus of family medicine at Brown University’s Alpert Medical School in Providence, R.I. Dr. Smith has led the National Physicians Alliance efforts to develop priorities in primary care settings for improving quality and reducing risks and costs of care. Treating mild to moderate sinusitis was number two on the family medicine list.

“I’m optimistic that we’ve reached a point where the culture is ready for change,” Dr. Smith said. Toward that end, Dr. Smith has worked at educating both patients and doctors that symptomatic relief, not antibiotics, is the standard of care.