Antibiotics Grossly Overprescribed for Sinus Infections

OMAHA, Neb., March 19 -- Antibiotics are prescribed for 70% to 80% of sinus infections even though most are caused by viruses, researchers here reported.

The use of antibiotics for acute and chronic rhinosinusitis far outweighs the predicted prevalence of bacterial causes of these conditions, reported Hadley Sharp, B.S., and Donald Leopold, M.D., of the University of Nebraska here, and colleagues, in the March issue of the Archives of Otolaryngology-Head and Neck Surgery.

Given the concern about antibiotic resistance and increasingly virulent bacteria, when two-thirds of patients with sinus symptoms expect or receive an antibiotic, these disorders hold special pertinence.

The researchers used data for 1999 to 2002 from two national surveys (the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey) conducted by the National Center for Health Statistics.

They found that an estimated 14,277,026 visits were made to health care facilities for chronic rhinosinusitis (symptoms lasting 12 or more weeks) and 3,116,142 for acute infections (symptoms up to four weeks). In 2002, rhinosinusitis accounted for 21% of all antibiotic prescriptions for adults and 9% for children.

At least one antibiotic was prescribed at 82.74% of visits for an acute infection, and at 69.95% of visits for a chronic infection in which inflammation is actually the most likely cause, the investigators reported.

After antibiotics, the drugs most used were antihistamines, nasal decongestants, corticosteroids, and antitussive, expectorant, and mucolytic agents, the authors wrote.

Furthermore, despite contradictory efficacies reported in the literature, inhaled or nasal corticosteroids were used in 15.05% of visits for acute cases, a rate more often than published studies imply is necessary, the researchers said. The use of corticosteroids although "not rare" in this setting, is of "undetermined benefit," they noted.

Within the class of antibiotics, penicillins, mainly amoxicillin and amoxicillin-clavulanate potassium (Augmentin), were appropriately the most commonly used medication class for both chronic and acute bacterial sinusitis, the investigators said. A penicillin drug was mentioned in 30.35% of all visits for chronic infection and in 27.18% of visits for acute infection.

Questionable, the researchers said, is the frequent use of the antibiotic class that included erythromycins, lincosamides, and macrolides, as well as other classes having higher antimicrobial efficacy.

The use of these drugs in 24.32% of acute visits put these antibiotics ahead of cephalosporins, sulfonamides and trimethprim, and tetracyclines, in that order, the researchers said.

An area where the findings fit nicely with current recommendations, the researchers said, is the use of antihistamines, which roughly matched the 20% U.S. prevalence of their major indication, allergic rhinosinusitis. The use of antihistamines (20.93% of visits for chronic sinusitis and 25.26% for acute cases) seemed logical, they said.

In discussing the complexity of acute and chronic rhinosinusitis, the researchers noted that it is understandable why the approach to treatment remains controversial.

Inasmuch as viruses are often involved in the acute form, many advocate no treatment if the symptoms are not severe, wane in five to seven days, and resolve in 10 days. There are guidelines for treatment of the acute forms and especially for acute bacterial rhinosinusitis. However, chronic disorders are more complex, they said.

A limitation of this study is that the use of over-the-counter medicines or home remedies was not recorded. The use of hot packs or physician-recommended irrigation with saline solution may have been used as often as an antihistamine prescription.

The vast use of antibiotics suggests that they seem to be effective or they would have been abandoned, the researchers said. However, they added, another possibility is that many patients have self-limited disease, while their physicians prescribe what they think will work. In time, however, may infections resolve regardless of treatment.

"To attribute efficacy or curative credit to a drug class based solely on resolution of symptoms without comparison with nontreated control subject, physicians could be oversatisifed with their own prescribing habits," the investigators concluded.