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QUESTION: Which antibiotics lead to higher clinical cure rates in adults with acute maxillary sinusitis?
Studies were identified by searching Medline and EMBASE/Excerpta Medica (to October 1998), scanning bibliographies of relevant articles, and contacting pharmaceutical companies and experts in the field.
Studies were selected if they were randomised controlled trials (RCTs) that compared an antibiotic with placebo or with another type of antibiotic in ≥30 patients who were ≥18 years of age and had a history consistent with acute maxillary sinusitis confirmed by radiography or aspiration.
2 or more reviewers independently extracted data on study characteristics; interventions; study duration; length of follow-up; co-interventions; compliance; and clinical, bacteriological, radiographic, and adverse event outcomes.
32 RCTs with 34 comparisons met the inclusion criteria. Treatment duration ranged from 3 to 15 days. Penicillin V, 1200 to 3960 mg/d, led to an increase in clinical cure or improvement rates (table). No difference in clinical cure was seen between the amoxicillin and control groups in 2 heterogeneous RCTs. Newer non-penicillin antibiotics had the same clinical cure rates as penicillin V or amoxicillin (8 RCTs); macrolides or cephalosporins had the same clinical cure rates as amoxicillin-clavulanate (8 RCTs). 5 RCTs that compared tetracyclines with a heterogeneous mix of antibiotics could not be meta-analysed.
Dropouts caused by adverse effects were fewer for macrolides or cephalosporins than for amoxicillin-clavulanate (9 RCTs) (table).
In adults with acute maxillary sinusitis, penicillin V or amoxicillin is more effective than placebo and as effective as non-penicillins for achieving clinical cure.
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.
Source of funding: no external funding.
For correspondence: Dr J Williams Jr, South Texas Veterans Health Care System, Audie Murphy Division, 7400 Merton Minter Boulevard, San Antonio, Texas 78284, USA.
A modified version of the abstract also appears in Evidence-Based Nursing