Antibiotics and Nasal Steroids Don't Improve Acute Sinusitis

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Summary and Comment

Antibiotics and Nasal Steroids Don’t Improve Acute Sinusitis

Neither amoxicillin nor nasal budesonide reduced duration or severity of symptoms compared with placebo.

Patient-perceived sinusitis is responsible for 25 million office visits per year in the U.S. Despite that the diagnosis is confirmed infrequently and that many cases are viral, antibiotic prescribing rates vary from 67% to 90% in the U.S. and western Europe. In a double-blind, randomized, placebo-controlled trial, researchers evaluated the efficacy of amoxicillin and nasal budesonide in 240 adults (>16 years) who presented to 58 family practices in the U.K. during a 4-year period with acute nonrecurrent sinusitis (defined as presence of at least 2 diagnostic criteria: purulent rhinorrhea with unilateral predominance, local pain with unilateral predominance, purulent rhinorrhea bilaterally, or pus in the nasal cavity). Patients received amoxicillin (500 mg three times per day for 7 days) plus nasal budesonide (200 µg once per day in each nostril for 10 days), or each agent with corresponding placebo, or only placebo.

The proportion of patients who were clinically cured at 10 days and the duration and severity of symptoms did not differ significantly among the groups receiving either of the active treatments, both active treatments, or no active treatment.

Comment: In the U.S., prescribing costs for acute sinusitis are approximately $2.4 billion per year, and a clear association has been demonstrated between an increase in resistant bacterial pathogens and increased use of antibiotics. The choice of amoxicillin for the study should not be criticized as a weakness, as three meta-analyses have failed to find that other, often more expensive, classes of antibiotics are more effective. Nasal steroids seem to have no effect overall, although in subgroup analysis they showed some benefit in milder cases. Educational efforts should target physicians who continue to prescribe antibiotics or nasal steroids for suspected acute sinusitis.

— John A. Marx, MD, FAAEM, FACEP

Published in Journal Watch Emergency Medicine January 11, 2008

Citation(s):

Williamson IG et al. Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: A randomized controlled trial. JAMA 2007 Dec 5; 298:2487.