August 18, 2008
Experts Move Away From Antibiotics for Sinusitis
By Anna Wilde Mathews
Sinus infections are among the most common and aggravating medical conditions, diagnosed in about 31 million Americans each year. And for most patients, treatment has long included an antibiotic.
Now, medical experts are pushing for a less-aggressive approach. About 21 percent of antibiotic prescriptions for adults in the U.S. are for sinusitis, even though studies show the drugs often do little or no good. Short-term sinusitis can be caused by either a bacterial infection, which may respond to treatment with antibiotics, or a viral infection, which doesn't. Doctors believe the overwhelming majority of cases begin as viral infections, and less than 2 percent of those turn into bacterial infections.
The American Academy of Otolaryngology - Head and Neck Surgery, which represents ear, nose and throat specialists, issued new guidelines last year for treating sinusitis. Among these: Doctors generally should wait 10 days before even considering an antibiotic. If the sinus sufferer is feeling better by then, the bug is almost surely a virus, and antibiotics would be of no use.
But if the problem lasts more than 10 days, chances are good it is bacterial. At this point, if the patient's illness is relatively mild, the guidelines leave it up to the doctor to decide between prescribing an antibiotic or monitoring the patient for as much as another week.
Some patients, and their doctors, might not be willing to wait. Keisha Herbin Smith knew what she wanted when she called her doctor's office last month about symptoms including congestion, a headache and a runny nose. Herbin Smith, a 30-year-old research coordinator from Woodbridge, Va., asked the nurse for an antibiotic to head off a full-blown sinus infection, so it wouldn't ruin a long- planned weekend at the beach. An antibiotic "just makes you feel better sooner," says Herbin Smith, who got her prescription and enjoyed her vacation, and later went to see her doctor when she returned.
Studies have shown that antibiotics may help at least some people with bacterial infections feel better faster. An analysis of 13 previous studies, performed for the academy to gather evidence for the new guidelines, found that 87 percent of sinusitis patients who took antibiotics felt better after seven to 12 days. But among patients who didn't take the drugs, 73 percent felt better by that point.
And the drugs have drawbacks. The analysis's lead author, Richard Rosenfeld, found that 25 percent of sinusitis patients who got antibiotics had side effects such as gastrointestinal problems, skin rashes or headaches. By contrast, among sinusitis sufferers who didn't take the drugs, 14 percent also had such problems. Widespread use of antibiotics is also blamed for the emergence of resistant bacteria.
"Certainly, the path of least resistance is to write an antibiotic," says Bradley Marple, a professor at the University of Texas Southwestern Medical Center in Dallas and a co-author of the new guidelines. Marple says he has gotten more comfortable in recent years with treating relatively mild sinus infections without the drugs. He says he sits down to discuss options with each patient.
Some patients are adjusting to drug-free treatments. Wendi Woolley, a graduate student at the University of Alabama, says her doctor recently gave her a saline rinse rather than an antibiotic for her sinus problem. "I don't want to take a chance" on possible drug side effects, she says.
Other medical authorities want to go even further than the academy's guidelines to minimize the use of antibiotics in treating sinusitis. An analysis by international researchers published in the Lancet medical journal in March said the drugs "are not justified even if a patient reports symptoms for longer than seven to 10 days." That's because the way doctors typically diagnose sinusitis, based on symptoms, isn't typically enough to determine which patients will benefit from antibiotics, the authors concluded.
Still, habits are hard to break. Daniel Merenstein, director of research programs for family medicine at Georgetown University, knows the arguments against antibiotics as well as anyone; he's a co- author of the Lancet analysis that recommended against their use. Merenstein says he nevertheless often prescribes an antibiotic for a patient after a week of difficult and worsening sinus symptoms, rather than waiting 10 to 17 days. "I think it's a patient expectation," he says.
Originally published by The Wall Street Journal.
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