Abstract
Acute rhinosinusitis is a common disease, in both children and adult patients, and happens most often in the setting of a viral infection with or without bacterial superinfection. Although spontaneous resolution is common, antibacterials are often prescribed and have a tremendous impact on costs, either directly or through the emergence of resistance in causative or colonising micro-organisms. The purpose of this work was to review published literature from 1989 to 2002 on antibacterial treatment in acute rhinosinusitis from a clinical and economical perspective.
A relatively small number of studies have compared antibacterials with placebo and few have suggested that antibacterials are superior to placebo, except when a bacterial cause is established or in the presence of specific CT-scan findings. On the other hand, 58 randomised controlled trials were published between 1989 and 2002, that compared the relative efficacy of various antibacterials. Most of these studies had serious methodological flaws, and no single antibacterial proved superior to its comparators.
Economic data are scarce and indicate cost of disease is high. Of the different treatment strategies assessed symptomatic treatment (patients being treated with antibacterials only if they failed to improve after 7 days) was the most cost-effective approach, compared with treating patients on the basis of specific clinical criteria, empirical treatment (all patients initially treated with antibacterials), or radiology-guided treatment. Cost effectiveness varied with disease prevalence.
In conclusion, this pharmacoeconomic review of antibacterial use in acute rhinosinusitis shows the need for improvement in the quality of the studies feeding economic analyses, but suggests that huge financial interests are at stake. Savings achievable, by better targeting patients needing antibacterial treatment, could be substantial, and more practical and precise diagnostic procedures are clearly needed. Acute rhinosinusitis is a typical example of a clinical dilemma in which good clinical practice must be balanced against imperfect information and patients’ individual interests balanced against society’s interest.
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References
Gwaltney JM. Sinusitis. In: Fauci AS, Braunwald E, Isselbacher KJ, et al., editors. Harrison’s principles of internal medicine. 14th ed. New York: McGraw-Hill, 1998: 676–86
McCaig LF, Hughes JM. Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA 1995; 273: 214–9
Pfaller MA, Ehrhardt AF, Jones RN. Frequency of pathogen occurrence and antimicrobial susceptibility among community-acquired respiratory tract infections in the Respiratory Surveillance Program Study: microbiology from the medical office practice environment. Am J Med 2001; 111 (9A): 4S-12S
Sokol W. Epidemiology of sinusitis in the primary care setting: results from the 1999–2000 Respiratory Surveillance Program. Am J Med 2001; 111 (9A): 19S–24S
De Bock GH, van Duijn NP, Dagnelie CF, et al. Nederlands Huisartsen Genootschap Standaard Sinusitis. Huisarts Wet 1993; 36: 255–7
Low DE, Desrosiers M, McSherry J, et al. A practical guide for the diagnosis and treatment of acute sinusitis. CMAJ 1997; 156: S1–S14
Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibacterial use for acute rhinosinusitis in adults: background. Ann Emerg Med 2001; 37: 703–10
American Academy of Pediatrics. Clinical practice guideline: management of sinusitis. Pediatrics 2001; 108: 798–808
Trinh N, Ngo HH. Practice variations in the management of sinusitis. J Otolaryngol 2000; 29: 211–7
Ray NF, Baraniuk JN, Thamer M, et al. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol 1996; 103: 408–14
Stalman W, van Essen GA, van der Graaf Y, et al. Maxillary sinusitis in adults: an evaluation of placebo-controlled doubleblind trials. Fam Pract 1997; 14: 124–9
Gananca M, Trabulsi LR. The therapeutic effects of cyclacillin in acute sinusitis: in vitro and in vivo correlations in a placebo-controlled study. Curr Med Res Opin 1973; 1: 362–8
Norrelund N. Behandling af sinusitis i almenpraksis. En kontrolleret undersogelse over pivampicillin. Ugeskr Laeger 1978; 140: 2792–5
Rantanen T, Arvilomi H. Double-blind trial of doxycicline in acute maxillary sinusitis: a clinical and bacteriological study. Acta Otolaryngol Stockh 1973; 76: 58–62
De Ferranti SD, Ioannidis JPA, Lau J, et al. Are amoxycillin and folate inhibitors as effective as other antibacterials for acute sinusitis?: a meta-analysis. BMJ 1998; 317: 632–8
Lindbaeck M, Hjortdahl P, Johnsen ULH. Randomised, double-blind, placebo controlled trial of penicillin V and amoxycillin in treatment of acute sinus infections in adults. BMJ 1996; 313: 325–9
Van Buchem FL, Knottnerus JA, Schrijnemaekers VJJ, et al. Primary-care based randomised placebo-controlled trial of antibacterial treatment in acute maxillary sinusitis. Lancet 1997; 349: 683–7
Stalman W, van Essen GA, Van der Graaf Y, et al. The end of antibiotic treatment in adults with acute sinusitis-like complaints in general practice?: a placebo-controlled double-blind randomised doxycycline trial. Br J Gen Pract 1997; 47: 794–9
De Bock GH, Dekker FW, Stolk J, et al. Antimicrobial treatment in acute maxillary sinusitis: a meta-analysis. J Clin Epidemiol 1997; 50: 881–90
Gehanno P, Depondt J, Barry B, et al. Comparison of cefpodoxime proxetil with cefaclor in the treatment of sinusitis. J Antimicrobial Chemother 1990; 26: 87–91
Ioannidis JPA, Contopoulos-Ioannidis DG, Chew P, et al. Meta-analysis of randomized controlled trials on the comparative efficacy and safety of azithromycin against other antibacterials for upper respiratory tract infections. J Antimicrobial Chemother 2001; 48: 677–89
Williams JW, Aguilar C, Makela M, et al. Antibiotics for acute maxillary sinusitis. Available in The Cochrane Library [database on disk and CD ROM]. Updated quarterly. The Cochrane Collaboration; issue 2. Oxford: Update Software, 2002
Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head NeckSurg 2000; 123 Suppl. 1: SI-S32
Ioannidis JPA, Lau J. Technical report: evidence for the diagnosis ant treatment of acute uncomplicated sinusitis in children: a systematic overview. Pediatrics 2001; 108: 1–8
Morris P. Antibiotics for persistent nasal discharge (rhinosinusitis) in children. Available in The Cochrane Library [database on disk and CD ROM]. Updated quarterly. The Cochrane Collaboration; issue 2. Oxford: Update Software, 2002
Halpern M, Schmier J, Richner R, et al. Antimicrobial treatment patterns, resource utilization, and charges associated with acute sinusitis in asthma patients. Am J Health Syst Pharm 2000; 57: 875–81
Benninger MS, Sedory Holzer SE, Lau J. Diagnosis and treatment of uncomplicated acute bacterial rhinosinusitis: summary of the agency for health care policy and research evidence-based report. Otolaryngol Head Neck Surg 2000; 122: 1–7
De Bock GH, van Erkel AR, Springer MP, et al. Antibiotic prescription for acute sinusitis in otherwise healthy adults: clinical cure in relation to costs. Scand J Prim Health Care 2001; 19: 58–63
Balk EM, Zucker DR, Engels EA, et al. Strategies for diagnosing and treating suspected acute bacterial sinusitis. J Gen Intern Med 2001; 16: 701–11
Laurier C, Lachaine J, Ducharme M. Economic evaluation of antibacterials in the treatment of acute sinusitis. Phannacoeconomics 1999; 15: 97–113
Pai CW, Ozcan YA, Jiang HJ. Regional variation in physician practice pattern: an examination of technical and cost efficiency for treating sinusitis. J Med Syst 2000; 24: 103–17
Kaiser L, Morabia A, Stalder H. Role of nasopharyngeal culture in antibacterial prescription for patients with common cold or acute sinusitis. Eur J Clin Microbiol Infect Dis 2001; 20: 445–51
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The study was carried out without external funding, and none of the authors has any potential conflicts of interest directly relevant to the content of this review.
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Wasserfallen, JB., Livio, F. & Zanetti, G. Acute Rhinosinusitis. PharmacoEconomics 22, 829–837 (2004). https://doi.org/10.2165/00019053-200422130-00002
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DOI: https://doi.org/10.2165/00019053-200422130-00002