Antibiotics are prescribed for nearly 83 percent of acute sinus infections, and roughly 70 percent of chronic sinus infections, despite the fact that viruses, not bacteria, are by far the most frequent cause of this condition, according to a report in the March issue of Archives of Otolaryngology–Head & Neck Surgery, one of the JAMA/Archives journals.
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Audio clips Donald Leopold, M.D., explains: The findings of the study. The frustration in diagnosing a sinus infection. The lack of FDA-approved medicines for treating sinus infections. Why saline rinses also help clear sinus infections. Why saline rinses should be the first course of action in treating a sinus infection. David Denman, M.D., discusses when it’s appropriate to prescribe antibiotics. Hadley Sharp, a UNMC medical student, explains why antibiotics are overprescribed. Video: Dr. Leopold performs a sinus exam. |
The study was conducted by the University of Nebraska Medical Center.
Rhinosinusitis, an inflammation of the sinus cavities (adjacent to the nasal passages) and commonly referred to as a sinus infection, is a common and expensive medical condition in the United States. In 2002, rhinosinusitis accounted for 21 percent of all antibiotic prescriptions for adults and 9 percent of those for children.
The impact of the study is large because it is estimated that 1 in 5 adults, and almost one in 10 children, on antibiotics, are taking them for sinus infections.
Most sinus infections are viral in origin, and therefore not effectively treated with antibiotics, yet patients are receiving antibiotics. Sinus infections caused by bacteria are effectively treated by antibiotics for most patients. Those who suffer from sinus infections seek relief for symptoms such as blocked nasal airflow, mucus, pressure and pain in the sinus areas.
Physicians say treating sinus infections is difficult because there are limited medications on the market for the condition and it is difficult to determine if the patient has an infection caused by bacteria or virus. Infection is considered acute when symptoms last up to four weeks, and chronic when symptoms persist for 12 weeks or longer. Acute rhinosinusitis is more commonly caused by infectious agents, while allergies, facial anatomy and hormonal changes may contribute to chronic cases.
Hadley Sharp, lead author of the paper, and colleagues at the University of Nebraska Medical Center Department of Otolaryngology-Head and Neck Surgery, used data from two national surveys to assess the medications prescribed for sinus infections at physicians’ offices and hospital outpatient and emergency departments between 1999 and 2002. The surveys were conducted by the National Center for Health Statistics and designed to be representative of the U.S. population.
Co-authors are Donald Leopold, M.D., professor and chairman, UNMC Department of Otolaryngology-Head and Neck Surgery, David Denman, M.D., Omaha ENT specialist, and Susan Puumala, UNMC Preventive and Societal Medicine.
“When two-thirds of patients with sinus symptoms expect or receive an antibiotic and as many as one-fifth of antibiotic prescriptions for adults are written for a drug to treat rhinosinusitis, these disorders hold special pertinence on the topic,” said Hadley, who is a senior medical student. “While keeping the goals of treatment in mind, there are concerns about the overuse of antibiotics and the resultant problems, including drug resistance and increasingly virulent bacteria.”
Based on the data collected in the surveys, an estimated 14.2 million visits to health care facilities nationally per year were due to chronic rhinosinusitis and 3.1 million were because of acute rhinosinusitis. The chronic visits represented 1.39 percent of total ambulatory care visits (in which the patient receives outpatient care), while acute cases represented .30 percent.
The most frequently recommended medications for treatment of both acute and chronic rhinosinusitis are antibiotic agents, followed by antihistamines, nasal decongestants, corticosteroids and antitussive, expectorant and mucolytic agents, respectively, the authors write. At least one antibiotic was prescribed at 82.74 percent of visits for acute rhinosinusitis and 69.95 percent of those for chronic rhinosinusitis.
“Prescription antibiotic drugs are being used far more than bacterial causes studies would indicate,” authors write. “Nasal and inhaled corticosteroids are prescribed more frequently to treat acute rhinosinusitis than published studies imply is effective.
“Despite current theories on causes of chronic rhinosinusitis, the use of corticosteroids remains low in this setting. An area where our findings fit nicely with current information is use of antihistamines, which roughly matched the prevalence of their major indication, allergic rhinosinusitis.”
Watchful waiting, saline rinse and use of a decongestant or appropriate antimicrobial agent are the preferred treatments, Dr. Leopold said.
“The data in our study says physicians aren’t following the suggested guidelines for treating sinus infections,” Dr. Leopold said. “However, we don’t know from the data how long the patients had their sinus infections before they got a prescription for antibiotics. We want to discourage physicians from prescribing antibiotics too often, ask patients not to inappropriately seek antibiotics and suggest looking at alternative treatments.”
It is possible that physicians may have been treating secondary infections with antibiotics in some cases, the authors note. In addition, physicians may believe that antibiotics are effective because patients improved while taking them, while in fact the symptoms may have cleared up without treatment.
“Finding relief from rhinosinusitis is difficult,” said Dr. Leopold, “because there are few good medications on the market for this condition. Steroid nasal sprays may offer some relief, but for those who suffer from chronic rhinosinusitis, prednisone may be needed. Because of the side affects associated with this drug, it should only be used when absolutely necessary.”
With few medications to choose from, and patients pushing their doctors for relief, many physicians probably feel pressured to prescribe antibiotics.
Dr. Leopold suggests another option that appears to be more effective and less costly than antibiotics: saline irrigation. “That, for me, has for many years been my main mode of therapy, and I don’t think the message is getting down to primary care physicians treating them,” he said. “I would suggest for someone with acute symptoms, viral or bacterial, treating with saline lavage (rinse) is the very best thing.”
He said saline rinsing can make symptoms go away, reduce inflammation, rid nasal passages of stagnant mucous and flush the nasal system, making it difficult for opportunistic infections to develop.
Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support. The article can be found here: