Commentary

Is this systematic review by Williams and colleagues the definitive work on management of sinusitis (also referred to as rhinosinusitis) that primary care internists have been awaiting?¹ The review, based on cases of sinusitis diagnosed by radiography and bacteriological tests, has determined that antimicrobial therapy with a course of penicillin or amoxicillin for 7 to 14 days is better than placebo and equal to newer, non-penicillins in management leading to clinical cure. Dropouts caused by adverse effects, however, were more frequent with amoxicillin-clavulanate than with cephalosporin.

Despite the clinical trials being done in mostly otolaryngological settings with diagnoses based on laboratory tests and radiography (rather than history and physical examinations used predominantly by the primary care physician), the newer generation of antibiotics provides no substantive benefit over penicillin or amoxicillin. The data about the usual organisms present and the cure rates obtained in this review show that no advantage exists for cephalosporins or macrolides over simple penicillins, except somewhat less frequent adverse effects.

The clinician judges clinical cure by noting symptom improvement in 3 to 5 days, with resolution of remaining symptoms by 10 to 14 days. Such additional investigative studies as endoscopy, plain or computed tomography, and bacteriological cultures are obtained for patients whose clinical course either does not respond to first line therapy or progresses rapidly, indicating a serious infection or central nervous system complication.²

This review does not answer all the questions for physicians who manage patients with rhinosinusitis. However, we now have clear evidence for appropriate selection of commonly used effective antimicrobial agents for first line therapy.