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Acute bacterial sinusitis. (Mindful Practice).

* A 3-day course of antibiotics may be as effective as a 10-day course in acute bacterial sinusitis.

* The chance of recurrence may be as high as 26% with a shorter course of antibiotics.

The Problem

A 32-year-old woman presents with a 4-day history of sinus congestion, unilateral facial pain, postnasal drainage, a mild sore throat, and green nasal discharge. She denies fevers or night sweats. One week before she developed a nonproductive cough; muscle aches; chills; rhinorrhea; and itchy, watery eyes. Her only medication is levothyroxine. She denies prior episodes of sinusitis, sinus surgery, or nasal polyps. She is allergic to penicillin. Her vital signs are normal, and she is afebrile. Her exam is remarkable for mild maxillary sinus pressure tenderness bilaterally and tenderness to palpation of the maxillary teeth. She may have acute bacterial sinusitis, based upon clinical criteria. Although a penicillin derivative would be the first choice, trimethoprim-sulfamethoxazole is considered because of her penicillin allergy The standard length of treatment for sinusitis is 10-14 days.

The Question

In patients with acute bacterial sinusitis, are shorter courses of antibiotics as effective as 10- to 14-day courses of antibiotics in decreasing time to resolution of symptoms and preventing recurrence of symptoms?

Seeking evidence: With use of the National Library of Medicine's PubMed search engine (www.pubmed.gov), a search is conducted with the search terms "sinusitis" and "therapy duration." The "limit" option is selected, as are "Randomized Controlled Trials" (Publication types) and "All Adult: 19+ years" (Ages).

Expert opinion: In our ENT outpatient practice, we generally treat with 7-10 days of antibiotics. I prefer amoxicillin / clavulanate because of possible resistance to amoxicillin alone in community-acquired sinusitis. Data from the 1950s suggest that among patients who received a decongestant alone, about 85%-90% improved. Patients should receive a nasal decongestant such as oxymetazoline for 3 days to avoid rebound nasal congestion.

Clinical decision: The patient will be treated based upon clinical suspicion; radiographs will not be obtained. The expert's practice is referral, but the study was conducted in a primary care setting. The results may not be applicable to his ENT practice but may be applicable to this patient. The patient is prescribed trimethoprim-sulfamethoxazole for 3 days along with a decongestant. By day 6, symptoms have resolved.

Assessor's summary: There is a higher risk of complications involving the central nervous system, the. orbit, and the periorbital tissues when the frontal and ethmoid sinuses are involved. Similarly, these results could nor be confidently applied to immunocompromised patients, patients with prior sinus surgery, patients with symptoms lasting longer than 30 days, patients with fevers above 38.6[degrees]C, or to the prescription of antibiotics other than trimethoprim-sulfamethoxazole. Finally, subjects had radiographic evidence of sinusitis, which means that the results may be less efficacious when applied to patients with a diagnosis of acute bacterial sinusitis based upon history and physical exam alone. This phenomenonis clue to the true cases being diluted out by the false-positive cases. Finally the 95% confidence interval for the difference between the 3-day and 10-day group indicates that recurrence may be as high as 26% for the 3-day group.

The Evidence

Randomized controlled trial of 3 vs. 10 days of trimethoprim/sulfa methoxazole for acute maxillary sinusitis.

JAMA 273(13):l015-21, 1995.

Setting: Primary care population attending general medical, employee health, and medical walk-in clinics of a Veterans Affairs Medical Center in Durham, N.C.

Design: Randomized, placebo-controlled clinical trial. Patient, physician, outcome assessors, and the statistician were blind to allocation.

Subjects: 80 consecutive males, 18 years old or older, with sinus symptoms (discharge, nontraumatic facial pain, and self-suspected sinusitis), and radiographically proven maxillary sinusitis (sinus opacity, air-fluid level, or mucous membrane thickening).

Interventions: Patients were randomly assigned to receive 10 days or 3 days of trimethoprim-sulfamethoxazole 160/800-mg twice daily. Patients assigned to the 3-day group received an 'identical-appearing placebo tablet for 7 days. All subjects received a decongestant nasal spray.

Limitations: All of the study subjects were men. Subjects with evidence of isolated frontal, ethmoid, or ethmoid and frontal sinusitis were excluded. Subjects with immunocompromised status, prior sinus surgery, or symptoms longer than 30 dabs were excluded. None of the enrolled subjects had temperatures higher than 38.6[degrees]C. Only one antibiotic was evaluated.

The Results

Median time to clinical success was similar--5.0 days for the 3-day and 4.5days for the 10-day groups. The limit to the confidence interval (CI) for the difference in median time to clinical success between the two groups crossed zero and was 3.25 days longer for the 10-day group. The percentage reporting cure or Improvement at day 14 was 77% for the 3-day group and 76% for the 10day group. Radiographic improvement also did not differ (3-day group: 240%j; 10-day: 25%): The between-group difference (3-day group minus the 10-day group) for relapses and recurrences was 7%.

Dr. Ebbert and Dr. Tangalos are with the Mayo C1inic in Rochester, Minn.
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Author:Ebbert, Jon O.; Tangalos, Eric
Publication:Internal Medicine News
Geographic Code:1USA
Date:Jan 15, 2002
Words:822
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