Antibiotics Overused In Sinusitis

By Elizabeth Agnvall
Special to The Washington Post
Tuesday, March 27, 2007

Antibiotics are still being prescribed for seven out of 10 patients with chronic sinus infections and eight out of 10 with acute sinus infections, even though research shows that more than 90 percent of the infections are caused by viruses -- not bacteria -- against which the drugs are useless, according to new research.

The study suggests that despite several years of physician awareness campaigns about the overuse of antibiotics, doctors and patients haven't gotten the message, say the authors, who describe their study as the largest to quantify physician habits in the treatment of sinus infections.

"Prescription antibiotic drugs are being used far more than bacterial causes would indicate," they wrote in the study, published last week in the Archives of Otolaryngology -- Head and Neck Surgery.

That behavior is problematic, they say, because overuse of antibiotics is behind the spread of increasingly virulent strains of drug-resistant bacteria. Sinus infections, which every year affect an estimated 37 million people in the United States and cost billions, account for 21 percent of all antibiotic prescriptions for adults and 9 percent of those for children. Acute sinusitis usually starts with a common cold and sinus inflammation and can last up to four weeks. Chronic sinusitis lasts for 12 weeks or longer.

Complaints of chronic sinusitis account for an estimated 14 million visits to doctors' offices, hospital clinics and emergency rooms, and acute sinusitis an additional 3 million, according to National Center for Health Statistics data analyzed by the researchers who conducted the new study. They found antibiotics were the most frequently recommended treatment for sinusitis, followed by antihistamines, nasal decongestants and nasal steroids.

Donald Leopold, professor and chair of otolaryngology at the University of Nebraska Medical Center and one of the study's authors, said at least part of doctors' prescribing habits might be explained by the difficulty of diagnosing some sinus infections. There is no quick swab test that determines whether an infection is bacterial or viral: To figure that out, doctors mainly consider the severity of symptoms and the duration of the infection.

Although most sinus infections start with a virus and get better within 10 days, some people develop a secondary bacterial infection. By the 10th day of symptoms, a majority of patients develop bacterial infections. Although most of these will resolve on their own, Leopold said, antibiotics are sometimes warranted, depending on the severity and duration of symptoms.

Because there is a common misconception that all sinus infections should be treated with antibiotics, Leopold said many patients demand the medication.

"Probably to save time, I will often knuckle under and give them the antibiotics, just because it's what they want," he said. "Often, it's patients I know who get into trouble once in a while and I don't want them to get into deeper trouble, so I give them the antibiotic."

Matthew Mintz, associate professor of medicine at the George Washington University School of Medicine, agrees that patient demand is part of the problem.

"We have advertisements on television from drug companies that basically tell you to ask your doctor for a pill," Mintz said. "We are a pill society. We want a pill to fix our problems."

While Mintz said he didn't dispute the prescribing pattern identified in the study, he questioned whether the researchers' methodology -- they extrapolated data from a large national survey -- might have exaggerated the problem. Mintz compared this kind of data sampling to an exit poll: "Sometimes they are right, and sometimes they can be drastically off."

David Fairbanks, a spokesman for the American Academy of Otolaryngology -- Head and Neck Surgery and a retired ear, nose and throat specialist, said physicians don't have time to spend 15 minutes with each patient explaining the public health implications of drug-resistant bacteria, so they write the prescription instead.

Fairbanks recommended urging patients to hold off on antibiotics for five to seven days after symptoms begin, to give their body a chance to fight off the infection.

But then, he said, "you get a patient who says, 'I can't wait -- I'm flying on an airplane, or I've got a PTA meeting, or I can't take off another day of work.' Somewhere between the fifth and seventh day comes physician judgment and how persuasive he can be with the patient." ยท

Elizabeth Agnvall is a frequent contributor to the Health section. Comments:health@washpost.com.


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