Antibiotics for clinically diagnosed acute rhinosinusitis in adults

Acute rhinosinusitis is a common condition that involves blockage of the nose passage and mucus in the sinuses. The diagnosis of acute rhinosinusitis in this review is based on clinical symptoms only, i.e. purulent discharge from the nose or other rhinosinusitis-like symptoms, such as unilateral facial pain or pressure, pain when bending forward, pain in the upper teeth or when chewing, and post-nasal drip. It is often caused by a viral upper respiratory tract infection of which only 0.5% to 2% of cases are estimated to be complicated by a bacterial rhinosinusitis. Nevertheless, antibiotics (used to treat bacterial infections) are often prescribed. Unnecessary prescribing contributes to antimicrobial resistance in the community. Therefore, in order to provide clinicians and patients with evidence-based guidance for management, it is important to assess the effect of antibiotics in acute rhinosinusitis.

We found 10 trials with a low risk of bias involving 2450 participants. Overall, about half of all participants were cured after one week with antibiotic or placebo treatment and three-quarters were cured after 14 days. Antibiotics can shorten the time to cure, but only five more participants per 100 will cure faster after 7 to 14 days if they receive antibiotics instead of placebo, or 18 participants will need to be treated with antibiotics for one extra patient to be cured more quickly. However, for every eight patients treated with antibiotics one patient experiences an adverse event caused by the treatment. The rate of serious complications was very low in both the placebo and antibiotic treatment groups.

Given the lack of clear benefit in terms of rapid recovery and the increase in side effects in participants treated with antibiotics, antibiotics are not recommended as first line treatment in adults with clinically diagnosed acute rhinosinusitis. This review cannot make recommendations for treatment of children, patients with a suppressed immune system and patients with severe disease as these populations were not included in the available trials. More studies are needed to identify which patients might benefit from antibiotics.

Authors' conclusions: 

The potential benefit of antibiotics in the treatment of clinically diagnosed acute rhinosinusitis needs to be seen in the context of a high prevalence of adverse events. Taking into account antibiotic resistance and the very low incidence of serious complications, we conclude that there is no place for antibiotics for the patient with clinically diagnosed, uncomplicated acute rhinosinusitis. This review cannot make recommendations for children, patients with a suppressed immune system and patients with severe disease, as these populations were not included in the available trials.

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Background: 

In primary care settings, the diagnosis of rhinosinusitis is generally based on clinical signs and symptoms. Technical investigations are not routinely performed, nor recommended. Individual trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear.

Objectives: 

To assess the effect of antibiotics in adults with clinically diagnosed rhinosinusitis in primary care settings.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2012), MEDLINE (January 1950 to February week 4, 2012) and EMBASE (January 1974 to February 2012).

Selection criteria: 

Randomised controlled trials (RCTs) of antibiotics versus placebo in participants with rhinosinusitis-like signs or symptoms.

Data collection and analysis: 

Two authors independently extracted data and assessed the risk of bias. We contacted trial authors for additional information. We collected information on adverse effects from the trials.

Main results: 

We included 10 trials involving 2450 participants. Overall, the risk of bias in these studies was low. Irrespective of the treatment group, 47% of participants were cured after one week and 71% after 14 days. Antibiotics can shorten the time to cure, but only five more participants per 100 will cure faster at any time point between 7 and 14 days if they receive antibiotics instead of placebo (number needed to treat to benefit (NNTB)) 18 (95% confidence interval (CI) 10 to 115, I2 statistic 0%, eight trials). Purulent secretion resolves faster with antibiotics (odds ratio (OR) 1.58 (95% CI 1.13 to 2.22)), (NNTB 11, 95% CI 6 to 51, I2 statistic 0%, three trials). However, 27% of the participants who received antibiotics and 15% of those who received placebo experienced adverse events (OR 2.10, 95% CI 1.60 to 2.77) (number needed to treat to harm (NNTH)) 8 (95% CI 6 to 13, I2 statistic 13%, seven trials). More participants in the placebo group needed to start antibiotic therapy because of an abnormal course of rhinosinusitis (OR 0.49, 95% CI 0.36 to 0.66), NNTH 20 (95% CI 14 to 35, I2 statistic 0%, eight trials). Only one disease-related complication (brain abscess) occurred in a patient treated with antibiotics.

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