Dr. Lovato is an associate professor at the David Geffen School of Medicine at UCLA, the ED director of clinical practice at Olive View-UCLA Medical Center, and the co-chair for the Emergency Medicine Best Practices Committee for the Los Angeles County Department of Health Services.
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Despite overwhelming evidence to the contrary, why are so many physicians giving their patients antibiotics for sinusitis? And broad-spectrum ones at that.
A whopping 81 percent of outpatients received antibiotics for acute sinusitis, according to a database review of more than 50,000 outpatient visits. Patients in 55 percent of those cases were prescribed a broad-spectrum antibiotic. (Fam Med 2006;38:349.)
The Centers for Disease Control and Prevention released several evidence-based guidelines in 2001 on the judicious use of antibiotics for upper respiratory infections, and a special report focused on the appropriate use of antibiotics for acute rhinosinusitis in adults. The guidelines were published in the Annals of Internal Medicine and the Annals of Emergency Medicine (2001;37:703), and were endorsed by the American Academy of Family Practice, the American College of Physicians, and the Infectious Diseases Society of America, among others.
These guidelines emphasized the viral etiology of most rhinosinusitis, recommending clinical diagnosis without imaging and reserving antibiotic therapy for patients with symptoms for more than a week accompanied by maxillary or tooth tenderness (especially unilateral) and purulent nasal secretions. The American Academy of Otolaryngology-Head and Neck Surgery published similar guidelines that suggested reserving antibiotics for symptoms lasting longer than 10 days or when suggestive sinusitis symptoms worsen after an initial period of improvement. (Otolaryngol Head Neck Surg 2007;137[3 Suppl]:S1.)
Why are physicians still prescribing antibiotics for sinusitis?
Amoxicillin for Acute Rhinosinusitis
Garbutt JM, Banister C, et al
This randomized, placebo-controlled trial was conducted in 10 primary care offices in St. Louis. Diagnostic criteria for acute bacterial sinusitis in this study required maxillary pain or tenderness in the face or teeth, purulent nasal secretions, and symptoms lasting more than seven days. Patients were excluded if they were allergic to penicillin, had antibiotics within the previous four weeks, had a history of complicated sinusitis, or had other immune-related comorbidities. Participants were randomized to receive a 10-day course of amoxicillin or a similar tasting placebo. Patients also received supportive therapy with acetaminophen, guaifenesin, dextromethorphan, pseudoephedrine, and saline nasal spray.
The primary outcome measure was disease-specific quality-of-life symptoms. Each patient graded 16 different sinus-related symptoms using a validated instrument called the Sinonasal Outcome Test-16 (SNOT-16) upon enrollment and on days three, seven, and 10. (Otolaryngol Head Neck Surg 1999;121:702.) Scores on the SNOT-16 range from 0 to 3, with lower scores indicating less severe symptoms. Analysis of similar quality-of-life instruments previously determined that a change in score of 0.5 was minimally important clinically. (J Clin Epidemiol 1994;47:81.)
No statistically significant difference was found in the percentage of patients with SNOT-16 improvement on day three (amoxicillin [37%] vs. placebo [34%], p=.67) or on day 10 (amoxicillin [78%] vs. control [80%], p=.71). The percentage of patients with symptom improvement reported on day seven, however, favored the treatment group (amoxicillin [74%] vs. placebo [56%], p=0.02). No differences in other quality-of-life measures were found: missed work, rates of relapse or recurrence, and satisfaction with treatment.
A statistically significant difference in percentage of patients reporting SNOT-16 improvement was seen on day seven in the amoxicillin-treated group. The mean difference in absolute SNOT-16 score improvement at that time was only 0.2 points, however, a change in score unlikely to have a measurable clinical impact. This finding lost statistical significance by day 10.
One could argue that this does not apply to patients in the ED because the study was done on ambulatory patients in a primary care setting. This may indeed be true. But if your ED is like most others, seasonal change brings a flood of patients with fever and the sniffles to the waiting room, either because they can't get an appointment with their primary care physician or because they don't have one.
It appears that the professional organizations got it right. Most rhinosinusitis is viral, especially when symptoms last less than seven days. Antibiotics are still unlikely to provide a cure even when a bacterial etiology is suspected, even when symptoms last more than seven days, and even accompanied by sinus pain and purulent discharge. Supportive care, time, and a little TLC are much more likely to make your patient better.
Hand Washing at UPMC Presbyterian
UPMC Presbyterian in Pittsburgh started a campaign last year to improve hand washing compliance, and reports documenting stiff thousand-dollar fines were quickly denied by the hospital.
Donald M. Yealy, MD, at the time said the fines were only to be "imposed when the lack of hygiene occurred despite clear markings of the patient room and notice by a trained infection control employee." (EMN 2011;33;33; http://bit.ly/UPMChandwashing.)
No fines had been distributed when EMN first reported the story, and Dr. Yealy said that remains true today. "Hand washing remains an opportunity throughout hospital with progress noted," he said in an email. The hospital has had no infectious outbreaks linked to hand washing.
* Read an abstract of the JAMA article, "Amoxicillin for Acute Rhinosinusitis," at http://1.usa.gov/AmoxSinus.
* Read all of Dr. Lovato's past columns in the EM-News.com archive.
* Comments about this article? Write to EMN at firstname.lastname@example.org.
© 2012 Lippincott Williams & Wilkins, Inc.