Sinusitis is one of the commonest reasons for visiting the doctor accounting for 15% to 21% of all adult outpatient antibiotic prescriptions. Patients may also present at dental practices, as pain from upper posterior teeth can be indistinguishable from sinusitis. Typical signs and symptoms are purulent nasal discharge, postnasal drip, sinus pain at palpation, nasal obstruction with poor response to decongestants, unilateral facial pain and maxillary toothache. The main aim this review was to assess the effects of antibiotics in adults with acute maxillary sinusitis by comparing antibiotics with placebo, antibiotics from different classes and the side effects of different treatments.
Searches were conducted in Cochrane CENTRAL, Medline, Embase, SIGLE, reference lists of identified trials and reviews, and ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). Randomised controlled trials (RCTs) that compared antibiotics with placebo or antibiotics from different classes for clinically diagnosed acute maxillary sinusitis (whether or not confirmed by imaging or bacterial culture) in adults were included. Study screening, quality assessment and data abstraction was conducted independently by two review authors. Risk rations and 95% confidence intervals were conducted for differences between intervention and control groups. Primary outcomes were clinical failure rates at 7 to 15 days and 16 to 60 days follow-up.
- 63 studies were included, 9 placebo-controlled studies (7 in primary care) involving 1915 patients and 54 studies comparing different classes of antibiotics (10 different comparisons)
- 5 studies at low risk of bias comparing penicillin or amoxicillin to placebo provided information on the main outcome: clinical failure rate at 7 to 15 days follow-up.
- Antibiotics decreased the risk of clinical failure (pooled RR of 0.66, 95% CI 0.47 to 0.94, 1084 participants randomised, 1058 evaluated, moderate quality evidence). But, the clinical benefit was small.
- Cure or improvement rates were high in both the placebo group (86%) and the antibiotic group (91%).
- Adverse effects in seven of the nine placebo-controlled studies (comparing penicillin, amoxicillin, azithromycin or moxicillin to placebo) were more common in antibiotic than in placebo groups (median of difference between groups 10.5%, range 2% to 23%).
- However, drop-outs due to adverse effects were rare in both groups: 1.5% in antibiotic groups and 1% in control groups.
- In the 10 head-to-head comparisons, none of the antibiotic preparations were superior to another. However, amoxicillin-clavulanate had significantly more drop-outs due to adverse effects than cephalosporins and macrolides.
The authors concluded
There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, about 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 levels
Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams Jr JW, Mäkelä M. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD000243. DOI: 10.1002/14651858.CD000243.pub3.
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