Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: 10 days of amoxicillin is effective for acute sinusitis

ACP J Club. 1997 Sep-Oct;127:41. doi:10.7326/ACPJC-1997-127-2-041


Source Citation

Low DE, Desrosiers M, McSherry J, et al. A practical guide for the diagnosis and treatment of acute sinusitis. Can Med Assoc J. 1997 Mar 15;156(6 Suppl):1S-14S.


Abstract

Objective

To evaluate the effectiveness of therapies and the accuracy of diagnostic procedures in patients with acute sinusitis.

Data sources

Studies were identified by searching MEDLINE (1980 to 1996) using the terms sinusitis, acute sinusitis, respiratory infections, upper respiratory infections, diagnosis, therapy, etiology, and antimicrobial resistance. Additional studies were identified by scanning the bibliographies of retrieved articles.

Study selection

Emphasis was placed on randomized controlled trials evaluating the effectiveness of treatment of acute sinusitis in otherwise-healthy persons. Studies with other research designs (e.g., nonrandomized controlled trials and descriptive studies) were also included in the review but were assigned a lower weight.

Data extraction

Data were extracted on drug type, dosage and duration of treatment, proportion of patients with clinical cure or improvement, and proportion of patients with proven bacteriologic cure. For those studies evaluating diagnostic accuracy, data were extracted on diagnostic procedure and positive and negative likelihood ratios.

Main results

3 randomized controlled trials found antimicrobial agents to be effective in treating acute sinusitis. In 1 study, patients receiving a decongestant and an 8- to 10-day course of antibiotic therapy showed greater clinical improvement than those who received the decongestant alone (P < 0.05). Another study, involving children, showed that the 3-day and 10-day cure rates were greater in children who had received amoxicillin than in those who had received placebo. A study evaluating the clinical cure rates for amoxicillin-clavulanate found that those rates did not differ from the clinical cure rates for other antimicrobial agents. Consensus supports the use of a 10-day course of antimicrobial therapy at the present time. For patients who are allergic to amoxicillin, trimethoprim-sulfamethoxazole is effective. No published placebo-controlled trials have evaluated the effectiveness of adjunct therapies, including topical or oral decongestants, antihistamines, systemic glucocorticoids, and irrigation of the nasal cavity. For the diagnosis of acute sinusitis, 3 symptoms (maxillary toothache, poor response to decongestants, and history of colored nasal discharge) and 2 signs (purulent nasal secretion and abnormal transillumination) were found to be the best predictors of sinusitis in a primary care setting. Acute sinusitis was effectively ruled out by < 2 signs or symptoms and ruled in by > 3 signs or symptoms. Radiographs were useful when the diagnosis was unclear.

Conclusions

A 10-day course of amoxicillin should be the first line of therapy for acute sinusitis. Selected clinical signs and symptoms are valid predictors of acute sinusitis.

Source of funding: Abbott Laboratories Canada.

For article reprint: Core Health Incorporated, 200-7135 West Credit Avenue, Building 1, Mississauga, Ontario L5N 6J7, Canada. FAX 416-586-8746.


Commentary

Acute sinusitis is a costly condition that afflicts many people; requires millions of visits to physicians; and results in restricted activities at work, home, and school (1). The Canadian Sinusitis Symposium convened in April 1996 to determine consensus for diagnosis and treatment of acute sinusitis.

This review included a detailed description of the anatomy of the paranasal sinuses, the pathophysiology of the inflammatory and infectious processes leading to clinical manifestations of acute sinusitis; a simple, understandable, and reproducible scheme for diagnosis; recommendations for selection of appropriate antimicrobials (drug of choice and alternative agents) and dosage and duration of treatment; vigilance strategies for complications; and suggestions for specialist referral.

However, few of the studies selected for review were based in primary care settings, where most patients are managed. The consensus conference also heavily emphasized participants who were not primary care physicians. Evaluation of the effectiveness of therapy did not include relapse rates at 2 to 3 weeks after a 10-day course of antimicrobials. Lastly, only healthy patients with acute sinusitis and no other predisposing or complicating conditions, such as allergic rhinitis or previous use of over-the-counter remedies for prolonged symptoms, were included for review.

Despite its limitations in perspective, this is a useful review for the management of acute sinusitis. Further research on clinical outcomes, such as cure rates and complication rates, will provide future validation of the effectiveness of these recommendations in primary care.

Frank Sparandero, MD
Franciscan Health System of New JerseyJersey City, New Jersey, USA

Frank Sparandero, MD
Franciscan Health System of New Jersey
Jersey City, New Jersey, USA


Reference

1. Guarderas JC. Rhinitis and sinusitis: office management. Mayo Clin Proc. 1996;71:882-8.