ArticlesAntibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data
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 No summary of final results was available for the unpublished trial.33 Individual patients' data were available for all but the earliest trial.24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
References (51)
- et al.
Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods
Ann Intern Med
(2001) - et al.
Outpatient antibiotic use in Europe and association with resistance: a cross-national database study
Lancet
(2005) Resistance to antibiotics: are we in the post-antibiotic era?
Arch Med Res
(2005)- et al.
Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background
Ann Intern Med
(2001) - et al.
Clinical practice guideline: Adult sinusitis
Arch Otolaryngol Head Neck Surg
(2007) - et al.
The clinical diagnosis of acute bacterial rhinosinusitis in general practice and its therapeutic consequences
J Clin Epidemiol
(2003) Choice of effect measure for epidemiological data
J Clin Epidemiol
(2000)- et al.
Treating acute rhinosinusitis: Comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo
J Allergy Clin Immunol
(2005) - et al.
National ambulatory medical care survey: 2005 summary
(2007) - et al.
Use of antibiotics for adult upper respiratory infections in outpatient settings: a national ambulatory network study
Fam Med
(2006)
Management of acute maxillary sinusitis in Finnish primary care. Results from the nationwide MIKSTRA study
Scand J Prim Health Care
Variations in antibiotic prescribing and consultation rates for acute respiratory infection in UK general practices 1995–2000
Br J Gen Pract
Management of upper respiratory tract infections in Dutch general practice; antibiotic prescribing rates and incidences in 1987 and 2001
Fam Pract
Acute sinusitis, antibiotics, and the Holy Grail
J Fam Pract
Invasive methicillin-resistant Staphylococcus aureus infections in the United States
JAMA
Epidemiology of drug resistance: implications for a post-antimicrobial era
Science
Resistance to antimicrobial drugs—a worldwide calamity
Ann Intern Med
Antibiotics for clinically diagnosed acute rhinosinusitis in adults (protocol)
Cochrane Database Syst Rev
Meta-analysis: formulating, evaluating, combining, and reporting
Stat Med
A multilevel model framework for meta-analysis of clinical trials with binary outcomes
Stat Med
The relation between treatment benefit and underlying risk in meta-analysis
BMJ
Investigating underlying risk as a source of heterogeneity in meta-analysis
Stat Med
Multilevel models for meta-analysis, and their application to absolute risk differences
Stat Methods Med Res
Sifting the evidence-what's wrong with significance tests?
BMJ
Behandling af sinusitis i almenpraksis. En kontrolleret undersogelse over pivampicillin
Ugeskr Laeger
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