Another Strike Against Antibiotics for Sinus Infections

Sinus infections are responsible for 1 in 5 antibiotic prescriptions for adults, but a new study finds that the drugs offer no significant advantage over placebo.

Sinus infections are among the most common medical complaints for adults in the United States, and they are frequently treated with antibiotics despite limited evidence to support the practice. Results from a prospective study published in today’s edition of the Journal of the American Medical Association show that, even when prescribed under circumstances recommended by the Centers for Disease Control and Prevention (CDC), antibiotics are no better than placebo at providing relief for the infections. The study authors add that “watchful waiting” and provision of symptomatic treatment should be the preferred approach.

Currently, sinus infections are responsible for 1 in 5 antibiotic prescriptions for US adults. In 2001, evaluation and treatment guidelines developed by a CDC panel recommended that antibiotics be used only for sinus infections with moderately severe to severe symptoms. The new study, led by Jane M. Garbutt, MD, of the Washington University School of Medicine, was designed to test the effectiveness of these guidelines in the community setting.

The study included 166 participants, aged 18 to 70, who were recruited from 10 primary care practices in St. Louis and met the CDC criteria for acute bacterial rhinosinusitis with moderate, severe, or very severe symptoms. The most common symptoms at diagnosis were facial congestion or fullness, facial pain or pressure, cough, ear pain, postnasal discharge, nasal obstruction, and headache.

Participants received either a 10-day course of amoxicillin (1500 mg per day administered in 3 doses per day) or placebo. All participants also received symptomatic treatments as needed for pain or fever (acetaminophen), cough (guaifenesin and dextromethorphan hydrobromide), and nasal congestion (pseudoephedrine and saline spray). In all, 94% of the amoxicillin group and 90% of the control group made use of the symptomatic treatments.

Treatment effectiveness was measured via phone interviews on day 3, 7, 10, and 28 using the Sinonasal Outcome Test 16 (SNOT-16), which gauges the severity of 16 sinus-related symptoms, patients’ assessment of their symptoms and ability to function, rates of recurrence or relapse, and adverse effects of treatment. The results showed that the average reduction in SNOT-16 test scores was similar in both groups on day 3 (0.59 for the amoxicillin group; 0.54 for the control group) and day 10 (average difference between the groups’ scores of 0.01), although they differed on day 7, when the amoxicillin group was an average of 0.19 points lower.

In addition, the difference in reported symptom improvement was not significantly different on day 3 (37% for the amoxicillin group vs. 34% for the control group) or day 10 (78% for amoxicillin vs. 80% for control), although it was on day 7 (74% for amoxicillin vs. 56% for control). There was also no difference between the groups in terms of days missed from work or the ability to perform customary activities; rate of relapse or recurrence by 28 days; additional health care use; or treatment satisfaction.

“Our findings support recommendations to avoid routine antibiotic treatment for patients with uncomplicated acute rhinosinusitis,” the authors concluded. They noted that, even though the advantage of amoxicillin over control at day 7 was statistically significant, it was “too small to represent any clinically important change.”

"We feel antibiotics are overused in the primary-care setting," said Dr. Garbutt in a statement. “We hope this study provides scientific evidence that doctors can use with patients to explain that an antibiotic is not likely to help an acute sinus infection."

Pharmacists can counsel patients with sinus infections on alternatives to antibiotics, including treatments for their symptoms. They can also assure patients that sinus infections tend to get better just as quickly without antibiotics as with them.

To read the study (registration may be required), click here.