Antibiotics overprescribed for sinus infections

The debate over the best treatment for rhinosinusitis continues while prescribing practices may be fueling the rise of resistant pathogens.

By Susan J. Landers — Posted April 16, 2007

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Antibiotics may not be the proper treatment for the majority of sinus infections, but many physicians continue to prescribe them -- probably out of frustration, said the author of a new study on this common but puzzling medical condition.

Researchers at the University of Nebraska examined data from two large national surveys and found that antibiotics are prescribed for the majority of cases of both acute and chronic rhinosinusitis, despite the fact that most of the infections are viral and are undeterred by the medications.

Their study is in the March Archives of Otolaryngology -- Head and Neck Surgery.

This abundance of antibiotics in circulation for the wrong reasons is thought to be one of the prime drivers behind the rise in the number of pathogens that are resistant to a range of these powerful medications. About 2 million people get bacterial infections in the nation's hospitals each year, and one in 10 dies, says the Infectious Diseases Society of America. About 70% of these infections are resistant to at least one drug.

Also troubling is the frequency with which such resistant infections are making appearances in communities around the nation, often attacking young, healthy people.

It seems that physicians' best intentions to treat appropriately are crumbling before an onslaught of congested patients, according to the study findings. But don't beat up on physicians too much, said study author Donald A. Leopold, MD, chair of the University of Nebraska Medical Center's Dept. of Otolaryngology-Head and Neck Surgery. "I think physicians are frustrated because there are no good medicines, especially for chronic sinusitis."

Millions of sinus infections

He and his colleagues assessed the medications prescribed for sinus infections at physicians' offices and hospital outpatient and emergency departments between 1999 and 2002. They determined that about 14 million visits each year were due to chronic sinus infections, while 3 million were because of acute infections.

At least one antibiotic was prescribed during nearly 83% of visits for acute rhinosinusitis and 70% of visits for chronic rhinosinusitis, according to the study. In 2002, the condition in general accounted for 9% of prescriptions for antibiotics in children and 21% in adults, the researchers said.

They found that the next most frequently recommended medication was an antihistamine, followed by nasal decongestants, corticosteroids and antitussive, expectorant and mucolytic agents. The researchers noted that nasal and inhaled corticosteroids are prescribed more often for acute rhinosinusitis than seems warranted by the research, while the use of corticosteroids for treating chronic conditions is probably too low.

Christopher Randolph, MD, associate clinical professor in pediatrics, allergy and immunology at Yale University in New Haven, Conn., wasn't very surprised by the findings. He considered it something of an unfortunate likelihood, given that antibiotics are overused and that conditions such as sinusitis are so poorly defined.

The entire realm of sinus infections from cause to treatment has been subject to controversy in recent years. One hot debate took place at a recent American Academy of Allergy Asthma and Immunology meeting, Dr. Randolph said. Sides were taken over whether chronic sinusitis is an inflammatory or an infectious condition. No resolution was reached.

Among the points agreed upon in guidelines published in December 2004 in the Journal of Allergy & Clinical Immunology and Otolaryngology -- Head and Neck Surgery was that additional research on acute and chronic sinusitis is essential.

Meanwhile, Dr. Randolph said he practices "antibiotic by anticipation" with his patients. "We tell patients that guidelines say if symptoms last 10 days despite treatment with a decongestant, we might offer antibiotics."

Physicians do endorse one tried-and-true treatment for sinus infections: saline irrigation or lavage. Dr. Leopold's patients are frequently told of the virtues of pouring salty water into each nostril. After patients get used to the idea. they actually like it, Dr. Leopold said.

Washing away the stagnant mucus makes sense, he said. "We know that most of the action takes place in the mucus of the nose."

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Rhinosinusitis facts

The study, "Treatment of Acute and Chronic Rhinosinusitis in the United States, 1999-2002," published in the March Archives of Otolaryngology -- Head and Neck Surgery, examined large databases to determine prescribing trends for the disorder commonly known as a sinus infection. The researchers found:

  • The most frequently recommended medications for treatment of both acute and chronic rhinosinusitis were antibiotics.
  • Penicillin was the antibiotic chosen most often.
  • The use of prescription antibiotics far outweighs the predicted incidence of bacterial causes of acute and chronic sinus infections.
  • In 2002, rhinosinusitis accounted for 9% of prescriptions for antibiotics in children and 21% in adults.
  • Despite contradictory reports from research studies about their effectiveness, nasal and inhaled corticosteroids also were commonly prescribed to treat acute rhinosinusitis.

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External links

National Institutes of Health on sinusitis, including treatment guidelines from several organizations (link)

Infectious Disease Society of America on antibiotic-resistant drugs (link)

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