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Three Part Question

In [adults with uncomplicated maxillary sinusitis] does [treatment with antibiotics] improve [outcome]

Clinical Scenario

A 27 year old woman attends the emergency department with a 4 day history of pain to her upper jaw (made worse by leaning forwards) and a green disharge from her nose. A diagnosis of acute maxillary sinusitis is made. She informs you that she is due to go on holiday in 2 weeks and would like some antibiotics to "make sure she is better" by then. You wonder whether antibiotics would be of benefit in this situation.

Search Strategy

Medline 1950 to 2009 via Search 2.0 engine Health Information Resources (formerly National Library for Health).
(sinusitis.mp.) OR (exp SINUSITIS/) AND (exp ANTI-BACTERIAL AGENTS/ OR antibiotic$.mp.) [Limit to: (Publication Types Clinical Trial, All) and Humans and (Age Groups All Adult 19 plus years) and English Language]
Cochrane Review Database Search.
Sinusitis AND Antibiotics

Search Outcome

A total of 218 papers were found on Medline of which 4 directly addressed the question.
Cochrane Library search found 1 systematic review published in April 2008

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Williamson IG et al 2007 UK	240 adults >=16 with acute nonrecurrent sinusitis. Patients received antibiotic and placebo topical steroid, antibiotic and topical steroid, placebo antibiotic and topical steroid or placebo antibiotic and placebo topical steroid.(Amoxicillin 500mg TDS 7 days and budesonide 200 microgrammes in each nostril once/day for 10 days)	PRCT	Symptoms lasting greater than 10 days.	No difference between antibiotics and placebo (adjusted odds ratio, 0.99;95% confidence interval, 0.57-1.73)	Fairly low numbers of patients, a reasonable number lost to follow up.
Van Buchem FL et al 1997 Netherlands	488 patients with clinical evidence of maxillary sinusitis. All patients included received xylometazoline 0.1% steam inhalations and Amoxicillin 750mg TDS for 7 days or placebo.	PRCT	"Cure" Rate after 2 weeks	No difference between antibiotic and placebo (p=0.06)	Lots of possible patients excluded from trial (only 214 of the original 488 included NOT due to original exclusion criteria)
Bucher HC et al 2003 USA	252 adult patients with purulent nasal disharge and maxillary and/or frontal pain for at least 48 hours. Patients were given Amoxicillin 875mg and Clavulanic Acid 125mg, or placebo twice a day for 6 days.	PRCT	Time to cure	No difference between groups at 1 and 2 weeks. Hazard ratio for the effect of antibiotic treatment on time to cure was 0.99 (95% CI, 0.68-1.45)	Inclusion criteria was changed during the trial due to insufficient numbers.
			Adverse effects	At days 7 and 14 diarrhoea was significantly more likely in the antibiotic group. Odds ratio 3.89 (95% CI 2.09-7.25) at 7 days.
Hanse JG et al 2000 Denmark	133 adult patients with a diagnosis of acute maxillary sinusitis based on pain and raised CRP or ESR. Treated with Penicillin V 1333mg twice daily or Placebo.	PRCT	Pain score and illness score	Significant reduction in pain score at 3 days (p=0.04)	Other treatments not taken into account ie. analgesia. Short study period (7 days).
Ahovuo-Saloranta A et al 2008 UK	The search strategy included the Cochrane register, Medline and Embase searching for RCTs. At least 2 review authors assessed for quality. 57 studies were included; 6 placebo RCTs and 51 comparing different antibiotics. 5 studies with a total of 631 patients was metaanalysed.	Systematic review of high quality RCTs.	Lack of cure or improvement at 7-15 days	Slight statistical significance in favor of antibiotics; RR of 0.66 (95% (CI) 0.44 to 0.98)	This systematic review did show a slight benefit of antibiotics versus placebo however it also showed that cure or improvement was high in both placebo (80%) and antibiotic groups (90%) at 15 days. It did not show that any antibiotics were superior to each other.
			Lack of total cure	Significant difference in favor of antibiotics; RR of 0.74 (95% CI 0.65 to 0.84) at 7 to 15 days follow up

Comment(s)

All of the studies included were conducted in the primary care setting which to a certain extent makes it less applicable to A&E. However as more patients seem to be presenting to A&E with "primary care problems" then it does becomes more relevant. The criteria for diagnosing acute bacterial sinusitis varied fom just the clinical picture through plain radiographs, blood inflammatory markers and up to computed tomography. The evidence in the systematic review although showing a slight benefit with antibiotics also demonstrated a high resolution of symptoms in both placebo and antibiotic groups given enough time.

Clinical Bottom Line

Most people will have improved significantly within 2 weeks with or without antibiotics. Given the small treatment effect of antibiotics versus the potential for adverse effects at the individual and population level antibiotics do not seem to be routinely indicated.

References

1. Willamson IG, Rumsby K, Benge S et al. Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis JAMA December 5, 2007—Vol 298, No. 21:2487-2496
2. Van Buchem FL, Knottnerus JA, Schrijnemaekers VJJ, Peeters MF Primary Care Based Placebo Randomised Control Trial of Antibiotic Treatment in Acute Maxillary Sinusitis The Lancet 1997;349:683-97
3. Bucher HC, Tschudi P, Young J, et al Effect of Amoxicillin-Clavulanate in Clinically Diagnosed Acute Rhinosinusitis Arch Intern Med 2003;163:1793-1798
4. Hansen JG, Schmidt H & Grinsted P Randomised double blind placebo controlled trial of penicillin V in the treatment of acute maxillary sinusitis in adults in general practice Scand J Prim Health Care 2000;18:44–47
5. Ahovuo-Saloranta A, Borisenko OV, Kovanen N, Varonen H, Rautakorpi UM,Williams Jr JW,Mäkelä M Antibiotics for acute maxillary sinusitis (Review) Cochrane Database of Systematic Reviews Issue 2, 2009