Evidence-Based Emergency MedicineAntibiotic treatment for acute maxillary sinusitis
Section snippets
Systematic review source
This is a systematic review abstract, a regular feature of the Annals' Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area.
The source for this systematic review abstract is: Williams JW, Aguilar C, Makela M, Cornell J, Hollman DR, Chiquette E, Simel DL. Antibiotics for acute maxillary sinusitis (Cochrane Review). In: The
Objective
To determine whether antibiotics are effective for acute maxillary sinusitis, and if so, whether any antibiotic class is superior.
Data sources
Trials were identified by MEDLINE and EMBASE searches through October 1998, requests to pharmaceutical companies for all published and unpublished trials, and bibliographies of included studies and previous systematic reviews.
Study selection
Studies were included if they were randomized trials of 30 or more adults that compared antibiotic with placebo, or antibiotics from different classes, for acute maxillary sinusitis. The studies were required to confirm the diagnosis by radiography or sinus aspiration and report outcomes in terms of clinical cure or improvement.
Data extraction
Two authors independently selected trials, extracted data, and assessed the quality of the trials. Primary outcomes were (1) clinical cure and (2) clinical cure or improvement. Secondary outcomes were radiographic improvement, relapse rates, and dropouts resulting from adverse effects.
Main results
Thirty-two trials, involving 7,330 patients, evaluated antibiotic treatment for acute maxillary sinusitis. Major comparisons were antibiotic versus control (n=5); newer, non-penicillin antibiotic versus penicillin class (n=10); and amoxicillin-clavulanate versus other extended spectrum antibiotics (n=10). Most trials were conducted in otolaryngology, non–emergency department settings. Of the 32 studies selected, 27 used conventional radiographs for diagnostic confirmation. Of these, 10 did not
Conclusions
For acute maxillary sinusitis confirmed radiographically or by aspiration, current evidence is limited but supports treatment with penicillin or amoxicillin for 7 to 14 days. Clinicians should weigh the moderate benefits of antibiotic treatment against the potential for adverse effects.
Cochrane Systematic Review Author Contact
John Williams, Jr., MD, MHS
Department of Medicine
Durham Veterans Affairs Medical Center/Duke University Medical Center
Durham, NC
E-mail [email protected]
Commentary: clinical implication
Rhinosinusitis is 1 of the 10 most common diagnoses in ambulatory practice and is the fifth most common diagnosis for which antibiotics are prescribed.1 However, it is estimated that up to 60% of such antibiotic prescriptions are unwarranted.2 The overuse of antibiotics in rhinosinusitis, as in other respiratory infections, is thought to contribute to the problem of increasing antibiotic resistance. How might the results of the Cochrane Review improve our approach to this problem?
Antibiotics
Take home message
Treatment of acute maxillary sinusitis with narrow spectrum antibiotics such as amoxicillin is supported by current evidence. However, benefit from antibiotics will be realized in clinical practice only if the target population has a similar prevalence of bacterial disease as in clinical trials, suggesting that treatment should be limited to patients who fulfill strict clinical criteria. Use of more expensive, broader spectrum antibiotics is not warranted for initial therapy.
EBEM Commentator
Evidence-based medicine teaching points
Publication bias. Systematic reviews combine the results of several trials, often using meta-analyses, to calculate a summary treatment effect. In an ideal systematic review, all relevant, methodologically sound studies on the topic are included; however, this is not always the case. A major potential source of error in systematic reviews is publication bias. Publication bias arises when studies are performed but not published, and therefore not included in the review. Research has shown that
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