1. The following clinical presentations (any of 3) are recommended for identifying patients with acute bacterial vs viral rhinosinusitis:
The FDA, in 2003, decided that this was a self-limited disease for which there was no evidence of a benefit for antibiotic treatment. So – who do you trust – the FDA or infectious diseases specialists?
Two recent studies examined this question. Both enrolled patients with signs and symptoms of sinusitis. Half the patients received placebo (sugar pill) and half received antibiotics. One was carried out in children and the antibiotic was amoxicillin-clavulanate (active against certain resistant strains of bacteria). The other studied adults and the antibiotic was amoxicillin – not active against certain resistant strains. The study in children found that the cure rate among antibiotic treated patients was 50% compared to 14% among those receiving placebo. At the same time, only 14% of those receiving antibiotics failed therapy while 68% of placebo recipients failed. The study of adults using amoxicillin showed no difference between amoxicillin and placebo. How could two similar studies come up with opposite results? Well – the most likely answer is that the study of adults was seriously flawed. First, the study only enrolled patients with severe symptoms early in the course of disease. But the guidelines have always suggested that patients with prolonged symptoms – 10 days or more and those that have had relapsing symptoms where they first started to get better then got worse again were good candidates for acute bacterial sinusitis that might benefit from antibiotics. The second flaw is that the study used amoxicillin that is not active against many resistant strains of bacteria that commonly cause sinusitis. In fact the new IDSA guidelines call for using amoxicillin-clavulanate as was used in the pediatric study where a clear benefit was identified.