Rx for Sinus Patients: Wait

By Francesca Lunzer Kritz
Special to The Washington Post
Tuesday, March 25, 2008

If you're one of the 20 million Americans who get a sinus infection each year, experts agree: You're being prescribed antibiotics too often. Now some are saying you shouldn't get them at all.

Antibiotics should never be prescribed for otherwise healthy adults with sinusitis, an analysis of a collection of studies concludes in The Lancet. Belgian and Swiss researchers who reviewed data from nine clinical trials involving more than 2,500 people with sinus infections found that the vast majority who received antibiotics didn't need them. That's because while 80 percent of patients diagnosed with an acute sinus infection are prescribed antibiotics, only 5 to 10 percent of such infections are bacterial and respond to the drugs. But doctors often have a hard time distinguishing between viral and bacterial strains.

Over-prescription of antibiotics for a host of medical conditions has led to widespread antibiotic resistance -- meaning doctors have fewer drugs effective against many bacterial infections.

But the Lancet study's conclusions conflict with sinus infection guidelines published last fall by the American Academy of Otolaryngology -- Head and Neck Surgery. Those guidelines recommend antibiotics (usually amoxicillin) if symptoms last more than 10 days. And some experts are calling the study's advice too extreme.

"There's no question that antibiotic resistance is a huge issue when it comes to treating sinusitis," said Richard Rosenfeld, chairman of otolaryngology at Long Island College Hospital in New York and the head of the task force that issued the guidelines. "After all, about 20 percent of all antibiotics prescribed for adults are given to treat sinus infections, and at least some of that is unnecessary."

But Rosenfeld and others said the Lancet analysis was not a sufficient basis for changing clinical practice because it was a meta-analysis, not a randomized trial comparing patients treated with and without antibiotics. What's more, said Rosenfeld, the analysis did not include patients diagnosed on the basis of CT scans, nasal cultures or other sophisticated tests.

"That means that patients most likely to have a bacterial sinus infection would have been excluded from the study," said Rosenfeld.

A 2007 study in the Archives of Otolaryngology -- Head and Neck Surgery by researchers at the University of Nebraska Medical Center was also critical of what it called over-prescription of antibiotics for sinus infections.

Sinuses are hollow spaces behind the nose, cheeks, forehead and eyes that are lined with mucous membranes. These membranes can become infected when a virus in the nose travels to the sinuses. Nose secretions caused by allergies, colds, cigarette smoke and environmental irritants can also travel to the sinuses and become trapped, causing a bacterial infection. In either case, said Stanley Chia, a staff otolaryngologist at the Washington Hospital Center, symptoms may include low-grade fever, pain and pressure behind the nose, headaches and a runny nose, sometimes with a colored discharge.

An infection that lasts up to four weeks is defined as an acute infection; one that lasts more than 12 weeks is considered chronic.

According to a press release that accompanied the Academy guidelines, sinus infections are among the most common and costly ailments of U.S. adults. Rodney Taylor , an associate professor of otolaryngology at the University of Maryland Medical Center, says doctors often prescribe antibiotics under pressure from patients anxious to stop the pain that often accompanies infections. Plus, he said, prescribing the drugs often takes less time for rushed doctors than explaining to a patient why drugs won't help.

Better treatment choices, according to the Academy, are cleansing with a saline solution or using a nonprescription decongestant. Many physicians also recommend nonprescription painkillers, as needed, to relieve headaches and fever.

An antibiotic prescription is warranted for sinusitis patients with chronic health problems such as heart disease or diabetes, which could be exacerbated by a bacterial infection, said Taylor. Antibiotics can also curtail rare spreads of the infection to the eyes and even to the brain, said Chia.

According to the Centers for Disease Control and Prevention, the number of bacteria resistant to antibiotics has increased in the past decade, and many major bacterial infections -- including tuberculosis, some pneumonias and a growing number of hospital-acquired illnesses -- are becoming resistant to common antibiotics, such as amoxicillin, and even last-resort ones such as methicillin and vancomycin.

But a patient with a pounding headache from sinusitis typically is more focused on relief than the state of world microbials, say experts. The challenge, particularly for primary care doctors who treat the bulk of sinus infections, is to figure out when an infection is bacterial and when not.

While otolaryngologists can rely on sophisticated tools such as endoscopes -- lighted tubes that can see inside nasal passages and detect pus in sinuses, a sign that an antibiotic may be needed -- primary care doctors usually rely on nose secretions and a patient's report, said Taylor. And while yellow or green mucus was once regarded as a sure sign of bacterial infection, doctors now know that this is not necessarily the case, leaving generalists without a clear sign of when to prescribe drugs. ^ and when not.

The Academy guidelines suggest that doctors consider prescribing antibiotics (usually amoxicillin) if symptoms - including colored nasal discharge - persist beyond 10 days, or improve within a 10-day period and then worsen.

Francesca Lunzer Kritz is a frequent contributor to the Health section. Comments: health@washpost.com.

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