Elsevier

The Lancet

Volume 371, Issue 9616, 15–21 March 2008, Pages 908-914
The Lancet

Articles
Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data

https://doi.org/10.1016/S0140-6736(08)60416-XGet rights and content

Summary

Background

Primary-care physicians continue to overprescribe antibiotics for acute rhinosinusitis because distinction between viral and bacterial sinus infection is difficult. We undertook a meta-analysis of randomised trials based on individual patients' data to assess whether common signs and symptoms can be used to identify a subgroup of patients who benefit from antibiotics.

Methods

We identified suitable trials—in which adult patients with rhinosinusitis-like complaints were randomly assigned to treatment with an antibiotic or a placebo—by searching the Cochrane Central Register of Controlled Trials, Medline, and Embase, and reference lists of reports describing such trials. Individual patients' data from 2547 adults in nine trials were checked and re-analysed. We assessed the overall effect of antibiotic treatment and the prognostic value of common signs and symptoms by the number needed to treat (NNT) with antibiotics to cure one additional patient.

Findings

15 patients with rhinosinusitis-like complaints would have to be given antibiotics before an additional patient was cured (95% CI NNT[benefit] 7 to NNT[harm] 190). Patients with purulent discharge in the pharynx took longer to cure than those without this sign; the NNT was 8 patients with this sign before one additional patient was cured (95% CI NNT[benefit] 4 to NNT[harm] 47). Patients who were older, reported symptoms for longer, or reported more severe symptoms also took longer to cure but were no more likely to benefit from antibiotics than other patients.

Interpretation

Common clinical signs and symptoms cannot identify patients with rhinosinusitis for whom treatment is clearly justified. Antibiotics are not justified even if a patient reports symptoms for longer than 7–10 days.

Introduction

An upper-respiratory-tract infection is the third most common reason for a doctor's consultation in the USA.1 About a third of these consultations are diagnosed as acute rhinosinusitis, and 80% of patients with this diagnosis are prescribed an antibiotic.2 In Europe, antibiotic prescription rates in primary care range from 72% to 92% for patients with acute rhinosinusitis.3, 4, 5

Primary-care physicians continue to overprescribe antibiotics for acute rhinosinusitis because distinction between viral and bacterial sinus infections is difficult.2, 6 In a primary-care setting, no test, sign, or symptom, or combination of these can clearly identify patients who benefit from antibiotics.7 Increased rates of antibiotic resistance are seen in countries where antibiotic use is highest and antimicrobial resistance has led to increased morbidity, mortality, and cost throughout the world.8, 9, 10, 11, 12

Guidelines therefore recommend deferral of antibiotic treatment until a patient has had symptoms for at least 7–10 days.13, 14 This recommendation was made on the basis of the time usually taken to progress from a viral to an established secondary bacterial infection, rather than on evidence from randomised trials. However, both discomfort and cost of additional office visits would be reduced if patients with a bacterial infection did not have to wait 7–10 days before starting treatment. We undertook an individual patient meta-analysis of randomised trials to assess whether common signs, symptoms, or specific patient characteristics can be used to identify a subgroup that would benefit from antibiotic treatment.

Section snippets

Trial selection

We requested individual patients' data from the investigators of all known trials in which adult patients with rhinosinusitis-like complaints were randomly assigned to treatment with an antibiotic or a placebo. Patients in these trials had to have clinical signs and symptoms of rhinosinusitis, such as a previous common cold or two stages of illness (symptoms initially improving then deteriorating), purulent nasal discharge, unilateral facial pain, toothache, pain when chewing, purulent

Results

We identified ten trials that met our inclusion criteria (table 1);24, 25, 26, 27, 28, 29, 30, 31, 32, 33 all trials were double-blind. No summary of final results was available for the unpublished trial.33 Individual patients' data were available for all but the earliest trial.24

Our intention-to-treat population consisted of 2640 patients. Two patients had to be excluded from our analysis because their randomised treatment was not known.29 One trial used a factorial design with four randomised

Discussion

Our analysis of 2547 patients from nine trials showed that 15 patients with rhinosinusitis-like complaints need to be given antibiotics before one additional patient benefits from treatment. Common clinical signs and symptoms could not identify a subgroup of patients for whom treatment was clearly justified. Although purulent discharge in the pharynx had some prognostic value, eight patients with this sign still needed to be treated before one additional patient benefited.

Previous meta-analyses

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