Monday, September 8, 2014

An evidence-based alternative to antibiotics for acute sinusitis

- Jennifer Middleton, MD, MPH

It's that time of year when the kids go back to school and bring home colds, or viral upper respiratory tract infections (URIs), to their families. These viral infections can progress to acute bacterial sinusitis (ABS), and in my office we are starting to see the usual fall uptick in "sinus" complaints. The September 1st edition of AFP reviews a Cochrane meta-analysis of intranasal corticosteroids' effect on ABS symptoms.

AFP provides the key details from this 2013 Cochrane review, which examined 4 studies and included about 2000 children and adults in total. The studies included patients who were both prescribed and not prescribed antibiotics. The Cochrane reviewers deemed 1 of these studies to be of low quality and excluded it from the meta-analysis. From the remaining 3 studies, the number needed to treat (NNT) with an intranasal corticosteroid (fluticasone, mometasone, or budesonide) to resolve or improve symptoms was 15.

Most patients with ABS will recover without an antibiotic, and the Choosing Wisely campaign exhorts us to avoid prescribing antibiotics unless symptoms are severe and/or persistent. The Choosing Wisely materials provide several alternate treatment recommendations, but patients may still be getting antibiotic prescriptions because it's more satisfying for us to write one than advise patients about rest, fluids, and salt water gargles. Pressures to keep patients satisfied may also influence our prescribing; you may recall hearing about a study from 2012 that correlated higher patient satisfaction scores with increased prescription costs (along with increased emergency department visits and mortality).

An AFP Curbside Consultation from 2005 provides guidance for responding to patients who insist on receiving an antibiotic for sinusitis despite clinician advice against it. The article recommends centering discussions on the risk of future harm to patients and their loved ones related to antibiotic resistance. Providing brochures and posters throughout the office that educate on appropriate antibiotic use can also be helpful. There's an AFP By Topic on Upper Respiratory Tract Infections if you'd like to read more.

The duty of tackling antibiotic resistance belongs to all of us; perhaps having an evidence-based alternative to antibiotics in the form of intranasal corticosteroids will decrease inappropriate antibiotic use along with the office practices described above.

How do you treat ABS? Will this Cochrane review change your practice?