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About a third of patients who present with upper respiratory infections are diagnosed with acute rhinosinusitis, and 80% of patients with this diagnosis receive antibiotics, even though no known criteria distinguish between viral and bacterial etiologies.
To determine whether a subgroup of patients could be identified that might derive benefit from antibiotics, researchers combined and reanalyzed individual patient data from nine clinical trials that involved 2547 adults with clinical signs and symptoms of rhinosinusitis who were randomized to receive antibiotics or placebo. No patient had undergone imaging or culture before randomization. Cure was assessed after 8 to 15 days in all trials.
The odds ratio for cure in the antibiotic group was 1.37. The estimated number needed to treat (NNT) with antibiotics to achieve 1 additional cure was 15; the NNT was similar in all trials. Symptom severity, symptom duration, and age did not predict increased benefit from antibiotic treatment. Patients with purulent pharyngeal discharge derived somewhat greater benefit from antibiotics than did other patients, but the NNT for patients in this group was still 8.
Young J et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: A meta-analysis of individual patient data. Lancet 2008 Mar 15; 371:908.
Comment
The authors conclude that adults with acute rhinosinusitis generally should not receive antibiotics, regardless of presenting signs and symptoms, and that guidelines that suggest antibiotic therapy after 7 days of symptoms are not supported by evidence. Some clinicians might argue that an NNT of 8 or 15 is sufficient to warrant antibiotic therapy, but any benefits must be weighed against risks for adverse effects and increased antimicrobial resistance. Of course, patients with unusual signs or symptoms (e.g., high fever, periorbital edema) suggesting a serious complication should be treated promptly with antibiotics.