Until a better test is discovered and because most cases of sinusitis resolve without antibiotic treatment, providing reassurance, analgesics, and perhaps decongestants for symptomatic relief is the preferred treatment for mild to moderate cases of less than 7 days’ duration. Patients with typical sinusitis symptoms and more severe facial pain probably do benefit from early antibiotic treatment.17
However, I find that watchful waiting is ineffective for patients who complain of recurring sinus infections. These patients present within the first few days of illness, insist that they have a sinus infection just like the last one, and want to “catch it before it gets too bad.” This argument sounds sensible enough, and I find it hard to refuse the request. Are these sinusitis-prone patients more likely to have a bacterial infection than patients with similar complaints and no past history of sinusitis?
Antibiotics for Sinusitis-Prone Patients
Alho and coworkers18 present results of a rare attempt to explore this question in this issue of JFP. They recruited 23 adults who claimed to have suffered from recurrent sinus infections (sinusitis-prone group) and 25 who did not, all of whom had self-diagnosed colds of 48 to 96 hours’ duration. They compared the clinical courses, CT findings, and viral and bacterial cultures of nasal secretions obtained by nasoendoscopy. The sinusitis-prone group (defined as at least 2 episodes in the past year) had significantly more facial pain and sinusitis-like changes on CT scan (65% vs 36%). However, the sinusitis-prone group was just as likely to have a positive nasal viral culture as the control group (70% vs 64%). Paradoxically, the sinusitis-prone group was less likely to have a positive culture for pathogenic bacteria on nasoendoscopy (9% vs 40%), a finding the authors claim correlates with bacterial growth in the sinuses.
Alho and colleagues suggest that these sinusitis-prone patients usually have viral respiratory tract infections, just like the non-sinusitis–prone patients. They believe that because the sinusitis-prone patients tend to have more severe facial pain from their colds, they are more likely to seek care, and they are therefore more likely to be prescribed antibiotics inappropriately for this viral infection. My equally plausible explanation is that sinusitis-prone patients are truly more likely to develop complicating bacterial sinus infection early in the course of their illnesses, and they should be treated more aggressively with early antibiotic treatment. We cannot know the correct explanation because Alho and coworkers did not randomly assign subjects with respect to antibiotic treatment and because no diagnostic sinus punctures were done to determine who truly had a bacterial sinus infection. In a study of clinical predictors Hansen and colleagues11 found no difference in bacterial sinusitis in patients with and without a history of sinusitis, a finding that supports the interpretation of Alho and coworkers.
Time to Change Prescription Habits?
In light of the findings of Alho and colleagues, should I change my practice of using antibiotics for sinusitis-prone patients? Their findings and those of Hansen and coworkers are intriguing enough for me to think twice before reflexively prescribing an antibiotic. I will delve more carefully into the patient’s history to convince myself that the past episodes sound more like significant sinus infections than allergy or simple URIs. In doubtful cases, a plain Waters sinus radiograph, if normal, effectively rules out bacterial infection (negative predictive value of approximately 90%, meaning that 90% of symptomatic patients with a normal radiograph do not have sinusitis). A positive radiograph, however, does not rule in bacterial infection, and in difficult cases a sinus CT may be helpful. Otherwise, it is necessary to go back to finding common ground with the patient and negotiating treatment. Clearly, a next step on the rhinosinusitis research agenda is a randomized clinical trial of antibiotic treatment for sinusitis-prone patients. Ultimately, an accurate, inexpensive, and convenient diagnostic test is needed before we can base antibiotic treatment of sinusitis-like illness on firm scientific grounds.