Running Head: LITERATURE REVIEW
1
Literature Review of Sinusitis & Antibiotics
Frances Connolly
NUR 652: Family Primary Care Health I
State University of New York: Polytechnic Institute
Fall 2014
SINUSITIS & ANTIBIOTICS
2
Literature Review of Sinusitis & Antibiotics
Sinusitis is a major cause for health care provider visits every year. Sinusitis has an
approximate annual cost of $5.8 billion and affects thirty-one million people in the United States
every year (Darrat et al, 2014). The treatment of sinusitis is not always agreed upon between the
patient and the health care provider. Acute bacterial sinusitis accounts for sixteen million clinical
visits each year (Dunphy, Winland-Brown, Porter & Thomas, 2011) and is the fifth leading cause
for prescribing antibiotics (Domino, 2014). Sinusitis is defined as a symptomatic inflammation
of the paranasal sinuses resulting from obstruction, impaired clearance and retained secretions
(Domino, 2014). Rhinosinusitis is the preferred term due to rhinitis and sinusitis usually
coexisting (Aring & Chan, 2011). The majority of cases are viral and antibiotics would not
improve or shorten the duration of the illness. The minority of cases are bacterial and can benefit
from a course of antibiotics. This literature review will decipher when prescribing antibiotics for
sinusitis is appropriate or not.
History, review of systems and physical assessment exam is enough to give the diagnosis,
but is rarely helpful in distinguishing bacterial from viral causes (Domino, 2014). Diagnosing
bacterial sinusitis is very difficult and using a compilation of symptoms and length of time
infected are the standard practice which will lead the health care provider to appropriate
treatment including whether to use antibiotics or not. The symptoms that the provider should
take into consideration when coming to the conclusion of prescribing antibiotics should include:
worsening of symptoms after 5-7 days with initial improvement, persistent symptoms for 10 days
or greater, persistent purulent nasal discharge, unilateral upper tooth or facial pain, unilateral
maxillary sinus tenderness, pain on bending and/or fever (Domino, 2014).
SINUSITIS & ANTIBIOTICS
3
As a health care provider it is important to decide between the risks vs benefits of treating
with supportive care for the pain and nasal symptoms or prescribing antibiotics. Most cases will
resolve with supportive care alone and antibiotics should be reserved for symptoms lasting
longer than one week. As a health care provider it is important to remember that there are risks
involved when prescribing antibiotics such as creating resistance to the antibiotics, adverse
effects, interactions with other medications and possible allergic reactions. It is important as a
health care provider to make the appropriate decision based on the symptoms to give the best
outcome in minimizing symptoms and duration of illness.
Method
The aim of the literature review will aid in coming to the appropriate decision for a health
care provider when deciding what treatment is best with a diagnosis of sinusitis. This review will
summarize the results of the scholarly articles and give positive and negative factors of
prescribing antibiotics for sinusitis and which antibiotics are appropriate to use.
The articles were obtained through a literary search of the databases via the SUNY
Polytechnic Institute Cayan Library including MEDLINE and CINAHL with full text. Another
search used was Google Scholar. Key terms used to guide the search were "sinusitis",
“antibiotics” and "treatment" together and separately. Inclusion criteria for the articles found
were that they were published between 2008-2014, full articles, English language and studies
showing the risks and benefits of using antibiotics for sinusitis. The search was expanded from
the typical last five years of studies due to lack of results, by searching one more year, able to
obtain an appropriate amount of results. Exclusion criteria included research on other respiratory
infections, other treatment uses for sinusitis and studies done outside the United States and
Canada. The final narrowed search rendered twenty-five articles and ten of those were chosen for
SINUSITIS & ANTIBIOTICS
4
this literature review. The twenty-five articles were reviewed for content and relevance. Google
Scholar was not used in the final decisions due to the volume of results that were difficult to
narrow down under thousands of results. The articles used were research studies, meta-analysis,
retro-spective studies, observational studies, randomized controlled trials, cross sectional review
and peer reviewed articles to identify the elements of the use of antibiotics in the treatment of
sinusitis. The articles that were chosen focused on antibiotic use specifically in the treatment of
sinusitis and the most appropriate class of medication to use to yield the best results.
Results
The purpose of the review is to gain the knowledge as a health care provider when to
prescribe antibiotics for sinusitis and when to treat with supportive care and if prescribing
antibiotics which are the most appropriate for each patient. The major commonality between all
of the literature was to wait on prescribing until at least seven days with symptoms of sinusitis.
Le Saux (2008) states that “most patients will recover between 7-10 days with acute viral
sinusitis and even those with acute bacterial sinusitis will recover 50-70% of the time without the
use of antibiotics”. Bailey and Chang (2009) states that the benefits of using antibiotics are
modest. The symptoms that will give the diagnosis of sinusitis must include at least one of the
following: purulent rhinorrhea, unilateral face pain, headache, teeth pain, sinus pain on bending
over, fever and/or worsening of symptoms after initial improvement (Cal et al, 2010). Meltzer
and Hamilos (2011) separate the symptoms into two categories: major or minor. The major
symptoms include purulent drainage, obstruction, facial fullness and pain, hyposmia and fever.
The minor symptoms include headache, earache, halitosis, dental pain, cough, fatigue and low
grade fever (Meltzer and Hamilos, 2011). As a provider the best way to treat sinusitis is to follow
clinical practice guidelines which are defined by Darrat et al (2014) as a “systematically
SINUSITIS & ANTIBIOTICS
5
developed statements to assist practitioner and patient decisions about appropriate healthcare for
specific clinical circumstances”.
“Approximately 20% of all antibiotics prescribed are for the treatment of sinusitis (Darrat
et al, 2014)”. Aring and Chan (2011) states that antibiotics should be reserved, in addition to the
typical timeframe, for patients who have moderate illness including moderate to severe pain and
a fever greater than or equal to 101 degrees, and anyone who is immunocompromised. Meltzer
and Hamilos (2011) found that appropriate treatment for mild illness is supportive care and
antibiotics should be added when moderate to severe illness. Sinusitis is a difficulty illness to
properly diagnose since diagnostic tests are not routine and to identify bacterial vs viral is based
on symptoms alone. This can lead to “prescribing antibiotics unjustly as well as patient-related
factors such as their expectations and pressure (Cals et al, 2010)”. Cox and Saluja (2008) discuss
the overuse of antibiotics especially with a diagnosis of sinusitis which leads to risk and
antibiotic resistance. Worrall (2008) found that the beneficial effects of antibiotic use are not
clinically significant and patients are more likely to develop adverse reactions.
Amoxicillin is the first-line antibiotic for treatment of acute bacterial rhinosinusitis in all
of the research articles. High dose amoxicillin or Augmentin have the lowest failure rate (Bailey
& Chang, 2009). The reasons to use amoxicillin is that they are safety, effect, cheap and have a
narrow microbiologic spectrum. Appropriate alternatives for a first-line treatment when there is a
penicillin allergy is macrolides or trimethoprim/sulfamethoxazole (Aring & Chan, 2011). These
two first-line antibiotics are what the clinical guidelines recommend in Darrat et al (2014) study
as well. Karageorgopoulos et al (2008) found that fluoroquinolones proved that there was no
benefits over beta-lactams and are not recommended as a first-line in treatment. On the other
hand the same study found a much better outcome with the use of amoxicillin-clavulanate as a
SINUSITIS & ANTIBIOTICS
6
first-line drug. Multiple studies had the same findings regarding the use of fluoroquinolones.
Suggested length of prescribing antibiotics range from a three to five day course to a ten to
fourteen day course. The shorter the course, the less adverse effects occur and Worrall (2008)
found that shorter courses were just as effective.
There are many negative points to think about when prescribing antibiotics. There is the
risk of obvious allergic reactions, there are adverse reactions and there becomes the major
problem of antibiotics resistant organisms. Common adverse effects of using antibiotics include
gastrointestinal issues such as nausea, vomiting, and diarrhea, rash, headaches and yeast
infections (Aring & Chan, 2011). Bailey and Chang (2009) states that the “potential risks of
adverse effects from antibiotics outweigh the benefits”. In one study by Vergidis et al (2011) the
focus was on patients over the age of 65 in which adverse effects can be much more serious and
even life threatening with the most common being Clostridium difficile. Interestingly enough the
number one prescribed antibiotic was fluoroquinolones in the study by Vergidis et al (2011)
which was found in a significant amount of other studies to be inappropriate and was found in
this study to be unjustified in two-thirds of the cases. The potential for developing antimicrobial
resistance is a serious problem in the United States (Bhattacharyya & Kepnes, 2008). A major
culprit in creating these resistant superbugs are the providers that prescribe antibiotics when they
are not necessary or when they are coerced into it by persistent patients and a prime example of
an illness that is causing these antimicrobial resistant strains is sinusitis. One method being used
by providers that can make the patient feel at ease as well as decreasing the actual use of
antibiotics is delayed prescriptions (Cal et al, 2010). Meaning that the prescription is written and
given to the patient to not use immediately but only if the symptoms persist or get worse.
Bhattacharyya and Kepnes (2008) found an increase in erythromycin resistant bacteria, a
SINUSITIS & ANTIBIOTICS
7
decrease in gentamycin and tetracycline and no change in methicillin’s, clindamycin, and
levofloxacin with the major bacteria being Staphylococcal aureus (MRSA), Streptococcus
pneumoniae and gram-negative organisms. Another finding by Le Saux (2008) is that
“fluoroquinolones can rapidly induce resistance in bacteria, especially Streptococcus
pneumoniae, which leads to treatment failure and therefore should be discouraged”. Cox and
Saluja (2008) found that providers were giving the diagnosis of sinusitis without fitting the
clinical criteria which then leads to an increased use of antibiotics in their observational study of
pediatric patients. Another factor to take into account when speaking about antibiotic resistant
organisms is the compliance of the patient. When prescribing as a provider, education that should
be included with every prescription of antibiotics given is to finish the entire course. Darrat et al
(2014) states that when providers lack awareness regarding clinical practice guidelines, potential
benefits can be missed in appropriate treatment.
Mild symptoms of sinusitis lasting less than seven days should be managed with
supportive care only which can include analgesics, decongestants, anti-histamines, mucolytics,
nasal saline wash and intranasal corticosteroids (Aring & Chan, 2011). Cal et al (2010) found no
significant difference in time to recovery when using antibiotics vs not using antibiotics.
Watchful waiting is recommended if pain is mild, temperature is less than 101 degrees and
patient has assurance to follow-up (Darrat et al, 2014). The clinical practice guidelines as stated
by Darrat et al (2014) for supportive care are followed in the other studies within this literature
review. Other supportive measures that should be encouraged is “steam inhalation, maintaining
hydration, warm face packs, elevating head of bed while sleeping and avoiding cigarette
smoking (Worrall, 2008)”. One supportive care intervention that was controversial within the
SINUSITIS & ANTIBIOTICS
8
current literature review was the use of intranasal corticosteroids. However, Meltzer and Hamilos
(2011) recommend the use of intranasal corticosteroids based on their evidence-based results
Bailey and Chang (2009) found that more high quality placebo-controlled trials are
necessary to appropriately prescribe when there are certain comorbidities. Cal et al (2010) found
that a delayed prescription plan may be beneficial with proper education and can decrease
actually antibiotics use while increasing patient satisfaction. 40% of patients found that delaying
prescriptions to be an acceptable strategy (Cal et al, 2010). Cox and Saluja (2008) found that
“relying on providers diagnosis of sinusitis, may mask instances of antibiotic overuse”. Darrat et
al (2014) found that to “improve compliance with the clinical practice guidelines, tools need to
be developed for providers that provide guidance and feedback so they can improve adherence”.
Conclusion
Diagnosis of the acute bacterial rhinosinusitis remains the 5th leading cause for
prescribing antibiotics and 2% of viral rhinosinusitis episodes have a bacterial superinfection
(Domino, 2014). There is a significant amount of literature reviews in regards to prescribing
antibiotics for the diagnosis of sinusitis. Important factors to take away from this review is to
follow the clinical practice guidelines to make appropriate decisions as a provider. There is a
significant amount of factors to take into consideration when prescribing antibiotics vs
recommending supportive care alone. An estimated 0.5% of all colds are complicated by
bacterial infection of the sinuses (Dunphy, Winland-Brown, Porter & Thomas, 2011).
As a provider one must weigh the potential adverse effects when prescribing antibiotics and also
appropriately giving the first-line vs second-line when appropriate. Supportive care is fairly
uncontroversial and therefore easy to educate and recommend to patients for most providers.
SINUSITIS & ANTIBIOTICS
9
Some supportive care needs to be reviewed when the patient has co-morbities that can interfere
with the benefits in some non-prescription medications.
In conclusion, antibiotics are appropriate to prescribe when indicated for sinusitis. The
difficulties is coming to the conclusion of what and how much of the criteria makes it
appropriate to prescribe antibiotics. The most impactful symptom a provider should start with
when deciding to begin an antibiotic or not is the duration of the illness. Another point to take
away for the provider is to not be bullied into prescribing because the patient is persistent about
wanting antibiotics. The best treatment a provider can give for any patient is the appropriate
treatment.
SINUSITIS & ANTIBIOTICS
10
References
Aring, A., & Chan, M. (2011). Acute rhinosinusitis in adults. American Family Physician, 83(9),
1057-1063.
Bailey, J., & Change, J. (2009). Antibiotics for acute maxillary sinusitis. American Family
Physician, 79(9), 757-758.
Bhattacharyya, N., & Kepnes, L. (2008). Assessment of trends in antimicrobial resistance in
chronic rhinosinusitis. Annals of Otology, Rhinology & Laryngology, 117(6), 448-452.
Cals, J., Schot, M., De Jong, S., Dinant, G., & Hopstaken, R. (2010). Point-of-care C-reactive
protein testing and antibiotic prescribing for respiratory tract infections: A randomized
controlled trial. Annals of Family Medicine, 8(2), 124-133. doi:10.1370/afm.1090
Cox, E., & Saluja, S. (2008). Criteria-based diagnosis and antibiotic overuse for upper
respiratory infections. Ambulatory Pediatrics, 8(4), 250-254.
Darrat, I., Yaremchuk, K., Payne, S., & Nelson, M. (2014). A study of adherence to the AAOHNS “Clinical practice guideline: Adult sinusitis”. ENT: Ear, Nose & Throat
Journal, 93(8), 338-352.
Domino, F.J. (2014). The 5-minute clinical consult 2014 (22nd ed.). Lippincott, Williams &
Wilkins, Philadelphia, PA.
Dunphy, L.M., Winland-Brown, J.E., Porter, B.O. & Thomas, D.J. (2011). Primary care: The art
and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F. A. Davis
Company.
Karageorgopoulos, D., Giannopoulou, K., Grammatikos, A., Dimopoulos, G., & Falagas, M.
(2008). Fluoroquinolones compared with beta-lactam antibiotics for the treatment of
SINUSITIS & ANTIBIOTICS
11
acute bacterial sinusitis: A meta-analysis of randomized controlled trials. CMAJ:
Canadian Medical Association Journal, 178(7), 845-854.
Le Saux, N. (2008). The treatment of acute bacterial sinusitis: No change is good
medicine. CMAJ: Canadian Medical Association Journal, 178(7), 865-866.
doi:10.1503/cmaj.080285
Meltzer, E., & Hamilos, D. (2011). Rhinosinusitis diagnosis and management for the clinician: A
synopsis of recent consensus guidelines. Mayo Clinic Proceedings. Mayo Clinic, 86(5),
427-443. doi:10.4065/mcp.2010.0392
Vergidis, P., Hamer, D. H., Meydani, S. N., Dallal, G. E., & Barlam, T. F. (2011). Patterns of
antimicrobial use for respiratory tract infections in older residents of long-term care
facilities. Journal of the American Geriatrics Society, 59(6), 1093-1098.
doi:10.1111/j.1532-5415.2011.03406.x
Worrall, G. (2008). Acute sinusitis. Canadian Family Physician, 5482-83.
SINUSITIS & ANTIBIOTICS
12
Appendix A
Study
Focus
Aring, A., & Chan, Research on
M. (2011)
diagnosing
and treatment
of sinusitis
and the risks
vs benefits of
using
antibiotics.
Bailey, J., &
Change, J. (2009)
Antibiotic use
in acute
sinusitis and
when it is
appropriate to
prescribe.
Subjects
Method
Adults with
rhinosinusitis
Compilation of
reviews: Systematic
review of 13
randomized trials of
antibiotic (abx) use in
adults with sinusitis.
Meta-analysis of
benefits of antibiotics
and a randomized,
double blind trial with
abx vs placebo.
Findings
In the systematic
review more than 70%
improved after 7 days
with or without abx.
8% resolved without
abx in 3-5 days &
35% in 7-12 days &
45% in 14-15 days.
Abx increased cure
rate by 15%. At 14-15
days abx were no
longer beneficial.
Adverse effects more
common with abx
than placebo. The
meta-analysis found a
slight favor in abx use
with an increase in
adverse effects. In the
double-blind trial, no
improvement was seen
with abx use at 14
days, the mean
number of days to
improvement with abx
was 8.1 and 10.7
without.
N=747 in the Compilation of
Evidence does not
double-blind
reviews: 5 doublesuggest that
trials.
blind trials comparing prescribing abx for
N=1891 in the abx use to placebo, 51 acute sinusitis due to
51 studies.
studies comparing
the fact that the
N=2547 in the abx treatments, and a adverse effects outmeta-analysis. meta-analysis
weigh the benefits of
comparing abx to
abx use. In the doubleplacebo. All were
blind studies
based on symptoms
improvement and cure
that lasted longer than rates were high in both
7 days.
abx group 90% and
placebo group 83%.
Adverse effects of
SINUSITIS & ANTIBIOTICS
13
Bhattacharyya, N.,
& Kepnes, L.
(2008).
Comparing
and
contrasting
the resistance
in abx use.
N=392
Cals, J., Schot, M.,
De Jong, S.,
Dinant, G., &
Hopstaken, R.
(2010)
Evaluation of
the effects of
C-reactive
proteins
(CRP) in
aiding in the
prescribing of
abx.
N=258 (151
with
rhinosinusitis)
penicillin ranged from
8-59%, amoxicillin
from 23-56%. In the
51 studies there was
not a significant
difference found
except in using
Augmentin. In the
meta-analysis, abx did
give significant
improvement, but also
increased adverse
effects.
Cross- sectional
The largest abx
review to find
resistance was seen
resistance to abx in
with erythromycin
chronic sinusitis.
use. Staphylococcus
Review of cultures
aureus (MRSA) was a
obtained from adults
significant finding in
with chronic sinusitis cultures with
with abx resistance
increased levels of abx
found. The study took resistance. Out of the
place over 4 years to
392 cultures taken,
see if resistance
701 types of bacteria
increased with time
were isolated. MRSA
and treatment.
was the highest at
19% at the start and
resistance of
erythromycin
increased throughout
the study with a max
resistance of 69.7% in
the last year of the
study. Resistance
decreased for
gentamycin and
tetracycline.
Randomized control
CRP testing can be
trial by 32 primary
useful in delaying
providers placed
prescribing abx and
patients in with the
can increase patient
CRP group or control satisfaction without
group which were
compromising
treated routinely.
actually recovery of
Timeliness of
illness. 43.4% of CRP
prescribing abx
patients used abx and
SINUSITIS & ANTIBIOTICS
14
varied. There was
also a 28 day followup appointment,
patient satisfaction
survey and clinical
recovery taken into
consideration.
Cox, E., & Saluja,
S. (2008)
Assessing the N=66
possibility of
providers over
diagnosing
bacterial
upper
respiratory
infections
(URI) and abx
overuse.
Observational study
of videotaped visits
for URI’s taking into
consideration
symptoms, physical
exam findings, tests,
diagnosis and
prescriptions.
Darrat, I.,
Yaremchuk, K.,
Payne, S., &
Nelson, M. (2014)
To see if
providers are
adhering to
clinical
practice
guidelines for
adult sinusitis
in regards to
diagnosis,
Retrospective study
with group of 10
otolaryngologists.
N=90
56.6% of the control
group used abx. In
follow-up 52.7% of
CRP group used abx
and 65.1% of the
control group.
Delayed prescriptions
were only filled 23%
in the CRP group and
72% in the control
group. Recovery was
comparable in both
groups and patient
satisfaction was high
in the CRP group.
Abx overuse occurred
3 times more
frequently than
necessary based on
diagnosis. The study
showed that providers
preemptively gave the
diagnosis of sinusitis
and treated with abx
that may not have
been necessary. The
criteria based
diagnosis of sinusitis
was agreed upon only
17% of the time. Abx
overuse occurred at
11% of visits that
were diagnosed by the
provider and 32%
based on criteria based
diagnosis.
Provider adherence
rate ranged from 0100% with overall
adherence being poor.
The adherence for
acute cases were
worse than with
chronic. With these
finding a worksheet
was developed to aid
SINUSITIS & ANTIBIOTICS
15
treatment and
prevention.
Karageorgopoulos,
D., Giannopoulou,
K., Grammatikos,
A., Dimopoulos,
G., & Falagas, M.
(2008)
Comparing
N=2133
the use of
different abx
in the
treatment of
acute bacterial
sinusitis
specifically
fluoroquinolo
nes and betalactams.
Meta-analysis of
randomized control
trials. 5 were
randomized and 4
were blind
randomized.
Le Saux, N. (2008) Evaluation of N=191
use of specific
antibiotics in
the treatment
of acute
bacterial
sinusitis
Literature review of a
meta-analysis
compiling results
from 191 articles
regarding the use of
specific antibiotics in
treatment of acute
bacterial sinusitis
Meltzer, E., &
Hamilos, D.
(2011)
The diagnosis
and
appropriate
management
of
rhinosinusitis
Meta-analysis and
literature review
Vergidis, P.,
Hamer, D. H.,
Meydani, S. N.,
Dallal, G. E., &
Barlam, T. F.
(2011)
To show the
patterns of
using abx in
the treatment
of respiratory
tract
infections in
long-term
care facilities
(LTCF).
N=617
Prospective,
randomized,
controlled study of
the effects of use of
Vitamin E as a
supportive treatment
in respiratory
infections. Study was
done in 33 LTCF’s
with participants 65
years of age or older.
with compliance of the
recommended
guidelines.
Fluoroquinolones
showed no benefits
over using betalactams and therefore
should not be used as
a first-line antibiotics
in the treatment of
acute bacterial
sinusitis. Adverse
effects occurred more
often with
fluoroquinolones.
Acute sinusitis usually
resolves without the
use of abx. Ampicillin
and cephalosporins are
just as effect as
levofloxacin, but the
fluoroquinolones can
induce abx resistance
and therefore should
not be used as a firstline treatment.
There continues to be
high rates of over
prescribing abx in the
treatment of acute
rhino-sinusitis. The
disconnect comes in
rating the severity of
symptoms
appropriately.
Abx were not
necessary in use for
one-fifth of respiratory
infections, suggesting
the need for
reeducation to
improve when
providers prescribe
abx. Treatment was
appropriate in 79% of
the episodes,
SINUSITIS & ANTIBIOTICS
16
inappropriate in 2%
and not necessary in
19%. Macrolides were
the most of any abx
that was used
inappropriately in
43% of cases.