Antibiotics for acute maxillary sinusitis

 

Abstract

Background

The role of antibiotics for sinusitis, one of the most common diagnoses among adults in ambulatory care, is controversial.

Objectives

We examined whether antibiotics are effective in treating acute sinusitis and, if so, which antibiotic classes are the most effective.

Search methods

We searched CENTRAL (2010, Issue 1) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to March Week 2, 2010) and EMBASE (1974 to March 2010).

Selection criteria

Randomised controlled trials (RCTs) comparing antibiotics with placebo or antibiotics from different classes for acute maxillary sinusitis in adults. We included trials with clinically diagnosed acute sinusitis, confirmed or not by imaging or bacterial culture.

Data collection and analysis

At least two review authors independently screened search results, extracted data and quality assessed trials. We calculated risk ratios (RR) for differences between intervention and control groups for whether the treatment failed or not. In meta-analysing the placebo-controlled studies, we combined the data across antibiotic classes. Primary outcomes were the clinical failure rates at seven to 15 days and 16 to 60 days follow up.

Main results

We included 59 studies in the review; six placebo-controlled studies (five of them conducted in primary care) and 53 studies comparing different classes of antibiotics. Five of the placebo-controlled studies (four low and one moderate/unclear risk of bias) involving 631 participants reported clinical failure rates (lack of cure or improvement) at seven to 15 days follow up. For participants with symptoms lasting at least seven days, antibiotics decreased the risk of clinical failure (pooled RR of 0.66, 95% confidence interval (CI) 0.44 to 0.98). However, the clinical benefit was small; cure or improvement rate was high in both the placebo group (80%) and the antibiotic group (90%). When clinical failure was defined as a lack of total cure (n = six studies), results were similar: antibiotics decreased the risk of failure (pooled RR of 0.74, 95% CI 0.65 to 0.84) at seven to 15 days follow up. In head-to-head comparisons, none of the antibiotic preparations was superior to the others.

Authors' conclusions

There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, 80% of participants treated without antibiotics improved within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population level.

 

Plain language summary

Antibiotics for acute maxillary sinusitis

Sinusitis is one of the most common reasons for visiting a doctor, with 20 million visits for this condition every year in the USA alone. There are four pairs of sinuses linked to the bony structures around the nose: the maxillary, frontal, ethmoidal and sphenoidal sinuses. In sinusitis, these membrane-lined air spaces become infected, which causes pain and discharge from the nose. Treatment options include decongestants, steroid drops or sprays, mucus-clearing drugs (mucolytics), antihistamines and antibiotics, and/or sinus puncture and lavage.

In most cases sinusitis accompanies viral cold infections where antibiotics are ineffective, but the few cases that have additional bacterial infections (one or two of every 100 patients with sinus symptoms) could benefit. Unfortunately it is difficult to distinguish between those who have bacterial infections and those who have not but it is important to avoid unnecessary use of antibiotics and thereby limit the potential for antibiotic resistance.

This systematic review drew together data from 59 separate studies that used a variety of antibiotics for simple maxillary sinus infection (i.e. non-complicated acute sinusitis in a person with a healthy immune system) in primary care settings. Six of the studies (747 participants) compared antibiotics to placebo and found that most of the participants got better within two weeks, regardless of whether they received the antibiotic or not. When antibiotics were given they somewhat speeded up recovery from sinusitis symptoms. In the remaining 53 studies comparing different antibiotics, none of the antibiotics were found to be superior to the others.

The small benefit gained by antibiotics may be overridden by the negative effects of the drugs. In addition to patient-related adverse effects (like skin rash and gastrointestinal problems, for example, diarrhoea, abdominal pain and vomiting), side effects include the risk of increased resistance to antibiotics among community-acquired pathogens.

This review found that antibiotics help some people a bit, but do not make a major difference to most people with acute maxillary sinusitis in primary care settings.

 

摘要

背景

抗生素治療急性上頜竇炎(acute maxillary sinusitis)

鼻竇炎是成人門診常見的診斷，而專家們對於抗生素治療的意見相當紛歧。

目標

我們研究抗生素是否能有效地治療急性鼻竇炎，而其中又以哪一類抗生素最為有效。

搜尋策略

我們檢索了Central Register of Controlled Trials(CENTRAL)(Cochrane圖書館，2007年第3期)、MEDLINE(1950年至2007年5月)以及EMBASE(1974年至2007年6月)。

選擇標準

比較抗生素與安慰劑、或不同種類抗生素之間治療成人急性上頜竇炎成效的隨機對照試驗(RCTs)。我們收錄了臨床診斷急性鼻竇炎的試驗，不論其診斷是否有經過X光檢查或細菌培養的確認。

資料收集與分析

至少有兩位作者各自瀏覽了搜尋的結果、擷取資料並評估試驗品質。我們計算了實驗與對照組的風險率(Risk ratios，RR)，以評估治療是否失敗。在統合分析安慰劑對照研究時，不同種類抗生素的數據結果都會被合併。主要結果(primary outcome)設定為第7至15天、以及第16至60天的治療失敗率。

主要結論

這篇文章共收錄了57個研究，其中包含6個比較抗生素與安慰劑的研究，以及51個比較不同類別抗生素的研究。其中5個研究(包含631個參與者)定義治療失敗為「7至15天內未達治癒或改善」，這些研究發現抗生素治療組有些微數據上的勝出，其RR為0.66(95％ CI 0.44 �0.98)；然而，兩組的治癒率及改善率均偏高(安慰劑組80％，抗生素組90％)，所以其臨床意義仍是模棱兩可。此外，有6個研究的治療失敗定義為「沒有痊瘉」，這些研究則發現抗生素治療組有顯著的勝出，其第7至15天的RR為0.74(95％CI 0.65 �0.84)。在這之中並無任何一種抗生素的治癒率較為優異。

作者結論

抗生素對於症狀超過7天、且未有併發症的急性鼻竇炎有些微的治療效果；而80％未曾接受抗生素治療的參與者，其症狀會在兩週之內自行改善。臨床醫生需權衡抗生素所帶來的小利，以及對病人與社會所造成的潛在不利影響。

翻譯人

本摘要由慈濟醫院陳迪詠翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

抗生素對於未有併發症的急性鼻竇炎有些微的治療效果，然而每10個病人當中，就有8個即使不用抗生素、也會在2週之內自行改善。抗生素些微的好處，可能遠不及其潛在對於個人及群體的不利影響。