Antibiotics Overprescribed for Sinus Infections

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Healthcare use of antibiotics far outweighs the predicted incidence of bacterial causes of acute and chronic sinusitis. That’s the conclusion of a new study published in the March 2007 issue of Archives of Otolaryngology – Head and Neck Surgery [1].

Antibiotics are only effective against bacterial infection. Many sinus infections are due to viral infection, allergies or hormonal changes. Physicians try to avoid antibiotic use to reduce the emergence of dangerous resistant bacterial strains, such as methicillin-resistant Staphylococcus aureus. However, most patients with sinus congestion want immediate relief and, because more effective drugs for chronic sinusitis are lacking, demand antibiotics.

The four-year prospective study found Americans made on average 4.25 million visits to healthcare facilities per year for sinus infection between 1999 and 2002. At least one antibiotic was prescribed in nearly 83% of cases of acute sinusitis and 70% of cases of chronic sinusitis. Antibiotics were prescribed more often than antihistamines, nasal decongestants, corticosteroids, and antitussive, expectorant, and mucolytic agents (order reflects the frequency of recommended medication).

The penicillins amoxicillin and amoxicillin-clavulanate potassium (brand name Augmentin) were the most commonly used antibiotics for both chronic and acute bacterial sinusitis. According to the Sinus and Allergy Health Partnership, the next most frequently used antibiotics should be erythromycins, lincosamides, and macrolides. However, the authors found cephalosporins, sulfonamides, trimethoprim, and tetracyclines were more commonly used.

Corticosteroids are used to reduce or prevent inflammation of the sinus mucous membranes. They do this by altering the actions of various cells of the immune system. Corticosteroids may be applied topically as a nasal spray or orally. Oral corticosteroids are rarely used to treat sinusitis. Prolonged use of oral corticosteroid treatments can cause serious side effects, including thinning of the bones, diabetes and increased risk of infection. Corticosteroid nasal sprays generally don’t cause these side effects. In addition, discontinuing use of corticosteroids does not lead to rebound congestion like topical nasal decongestants, frequently used to reduce sinus inflammation and congestion.

The use of corticosteroids was found in 15-16% of visits for acute and chronic cases of sinusitis. The authors maintain the rate of corticosteroid use is higher than published studies imply is necessary for acute sinusitis, while the rate may actually be lower than indicated for chronic sinusitis. Several studies suggest that intranasal corticosteroid use in conjunction with antibiotics are effective for improving the symptoms of acute sinusitis compared with antibiotic therapy alone [2-4]. Recent promising results from a study in patients with acute, uncomplicated sinusitis found that mometasone furoate (brand name Nasonex) nasal spray used twice daily produced significant symptom improvements versus amoxicillin and placebo, without predisposing the patient to disease recurrence or bacterial infection [5]. However, further studies may be needed to better clarify the role and proper dosage of corticosteroids when used alone or in combination with antibiotic therapy in the management of acute and chronic sinusitis.

The authors of the study express concern regarding the problems surrounding antibiotic overuse and conclude:

When two-thirds of patients with sinus symptoms expect or receive an antibiotic and as many as one-fifth of antibiotic prescriptions for adults are written for a drug to treat rhinosinusitis, these disorders hold special pertinence on the topic.

Increasing antibiotic resistance

Children average six to eight colds per year. Of those, only 0.5 to 5 percent will develop a sinus infection [7]. Nevertheless, sinusitis is the fifth most common diagnosis for which an antibiotic is prescribed [6]. There are a number of methods to determine whether a sinus infection is bacterial, including:

Nasal cytology – examining a swab from the lining of the nose.
Nasal endoscopy – running a tube into the nose to obtain a sample of mucus from the sinus cavity.
X-ray, computer tomography, magnetic resonance imaging (MRI) or ultrasound
Sinus puncture and bacterial culture — usually only performed if a reasonable diagnosis cannot be made using noninvasive techniques.

Unfortunately, all these methods are expensive and time-consuming.

A recent study found that 28% of Haemophilus influenzae strains cultured from patients with an acute exacerbation of chronic or acute sinusitis were resistant to ampicllin; 79% of Streptococcus pneumoniae strains were found to be penicillin-intermediate resistant [8]. An earlier study in 2001 in children with sinusitis found that 44% of Haemophilus influenzae cultures isolated were ampicillin resistant (41% having high-grade resistance) and 64% of Streptococcus pneumoniae isolates were resistant to penicillin (24% having high-grade resistance) [9].

Antibiotic resistance is an emerging public health crisis. Today, virtually all important bacterial infections in the United States and throughout the world are becoming resistant. The Centers for Disease Control and Prevention calls antibiotic resistance one of the world’s most pressing public health problems.

Remember

Taking antibiotics for viral infections will increase the risk of antibiotic resistance. Millions of antibiotics prescribed in doctors’ offices each year are for viral infections, which cannot effectively be treated with antibiotics. An alternative therapy for sinus infection is nasal irrigation, which can relieve symptoms, reduce inflammation and remove stagnant mucus in the nasal passages, making it difficult for infections to develop. The spread of viral infections can be reduced through frequent hand washing and by avoiding close contact with others.

References

Sharp et al. Treatment of acute and chronic rhinosinusitis in the United States, 1999-2002. Arch Otolaryngol Head Neck Surg. 2007 Mar;133(3):260-5.
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Meltzer et al. Intranasal flunisolide spray as an adjunct to oral antibiotic therapy for sinusitis. J Allergy Clin Immunol. 1993 Dec;92(6):812-23.
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Barlan et al. Intranasal budesonide spray as an adjunct to oral antibiotic therapy for acute sinusitis in children. Ann Allergy Asthma Immunol. 1997 Jun;78(6):598-601.
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Dolor et al. Comparison of cefuroxime with or without intranasal fluticasone for the treatment of rhinosinusitis. The CAFFS Trial: a randomized controlled trial. JAMA. 2001 Dec 26;286(24):3097-105.
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Meltzer et al. Treating acute rhinosinusitis: comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo. J Allergy Clin Immunol. 2005 Dec;116(6):1289-95. Epub 2005 Oct 24.
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Anon et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg. 2004 Jan;130(1 Suppl):1-45.
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Ramadan, HH. Pediatric sinusitis: update. J Otolaryngol. 2005 Jun;34 Suppl 1:S14-7.
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Tellez et al. Microbiology of acute sinusitis in Mexican patients. Arch Med Res. 2006 Apr;37(3):395-8.
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Slack et al. Antibiotic-resistant bacteria in pediatric chronic sinusitis. Pediatr Infect Dis J. 2001 Mar;20(3):247-50.
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