Patients insist on antibiotics for sinusitis? Here is a good reason to say “no”

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PURLs

Patients insist on antibiotics for sinusitis? Here is a good reason to say “no”

J Fam Pract. 2008 July;57(7):464-468

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References

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The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

CAVEATS: Refer seriously ill patients and complicated cases

A very important caveat to our recommendation is that seriously ill patients must be managed differently. Very infrequently a patient develops a serious complication of acute sinusitis such as brain abscess, periorbital cellulitis, or meningitis. Therefore, seriously ill patients with signs and symptoms of acute bacterial sinusitis, such as high fever, periorbital erythema or edema, severe headache, or intense facial pain must be carefully evaluated and treated with great caution and close follow-up. These patients should be referred immediately for consultation with an otolaryngologist.

FAST TRACK

Saline nasal spray and pain medications lead to fewer side effects and lower cost

Of course, mildly ill patients today may become quite ill tomorrow, so always provide advice to patients to return if they are getting worse, a good clinical practice for any condition that is usually benign but occasionally serious.

Patients who have prolonged or recurrent sinusitis symptoms need further evaluation for other diagnoses such as allergies, cystic fibrosis, fungal sinus infection, and other illnesses associated with immune compromise. These complicated patients benefit from consultation with an otolaryngologist who has a specific interest in chronic and recurrent sinusitis, and perhaps consultation from an infectious disease specialist as well.

CHALLENGES TO IMPLEMENTATION: The patient who wants a pill

Some patients may be accustomed to receiving an antibiotic prescription for their “sinus infections” and may resist conservative management. It may be difficult to convince them that antibiotics won’t make a difference when they attribute past resolution of symptoms to antibiotics.

Take enough time to educate your patients on the natural course of illness, the positive benefits of nasal saline, and the reasons not to use unnecessary antibiotics (eg, they are not effective, have potential adverse effects, and can contribute to future antibiotic resistance); this effort will save you time in future visits.¹⁰ A “just in case you don’t get better” prescription to be filled only if the patient is not improving in the next few days is about 50% effective in reducing antibiotic usage for upper respiratory infections.¹¹

FAST TRACK

Giving a prescription to be filled only if the patient does not improve is about 50% effective in reducing antibiotic usage

Acknowledgement

We acknowledge Sofia Medvedev of the University HealthSystem Consortium (UHC) in Oak Brook, IL for analysis of the National Ambulatory Medical Care Survey data.

PURLs methodology

This study was selected and evaluated using FPIN’s Priority Updates from the Research Literature (PURL) Surveillance System methodology. The criteria and findings leading to the selection of this study as a PURL can be accessed at www.jfponline.com/purls.