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1
NICE 69: National Institute for Health and Clinical Excellence. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008. (Clinical guideline 69). RATIONALE: Although there are no specific studies looking at delayed antibiotics for acute rhinosinusitis, NICE 69 recommends the same approach as for the other self limiting respiratory tract infections. The 7-day delay is recommended as systematic review shows no benefit of antibiotics in rhinosinusitis within the first 7 days.

2
Young J, De Sutter A, Merenstein D, van Essen GA, Kaiser L, Varonen H, Williamson I, Bucher HC. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet. 2008;371:908-914 RATIONALE: This meta-analysis included 2.547 pts from 9 Placebo-controlled trials. This primary care meta-analysis showed that 15 people would have to be given antibiotics before an additional patient was cured. The Odds Ratio of treatment effect for antibiotics relative to placebo was 1.37 (95% CI 1.13 to 1.66). A further sub-group analysis showed that those patients with purulent discharge were more likely to benefit from antibiotics with a NNT of 8. There was no additional benefit of antibiotics for: older patients; more severe symptoms or longer duration of symptoms.

3

Ahovuo-Saloranta A, Borisenko OV, Kovanen N, Varonene H, Rautakorpi UM, Williams Jr JW, Makela M. Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews 2008, Issue 2.Art. No.: CD000243. DOI:10.1002/14651858.CD000243.pub2. (Last assessed as up-to-date 28 May 2007) RATIONALE: This is a big clinical review (57 studies), that contained 6 placebo controlled trials.5 of these were in primary care and involved 631 patients. There was a slight statistical difference in favour of antibiotics compared with placebo (RR 0.66; 95%CI 0.65 to 0.84). Note cure/improvement rate was high in placebo group (80%) compared with the treatment group (90%). Antibiotics have a small treatment effect in patients with uncomplicated acute rhinosinusitis, in a primary care setting, for more than seven days.

4
Ah-See KW, Evans AS. Sinusitis and its management. BMJ 2007:334:358-61 RATIONALE: Adequate analgesia is becoming recognised as the first-line management for acute rhinosinusitis. Robust evidence for this is limited, as it is for analgesia use in general. This is partly due to the widespread accepted efficacy and tolerability of analgesics, that such research isnt deemed necessary. We have to make do with the consensus expert opinion.

5
Thomas M, Yawn B, Price D, Lund V, Mullol J, Fokkens W. EPOS Primary Care Guidelines: European Position Paper on the Primary Care Diagnosis and Management of Rhinosinusitis and Nasal Polyps 2007 – a summary. Primary Care Respiratory Journal 2008; 17(2): 79-89. RATIONALE: This primary care guideline states that: "Acute rhinosinusitis is an inflammatory condition that may be diagnosed on the basis of acute symptoms of nasal blockage, obstruction, congestion with or without facial pain or reduced smell; many episodes are self-limiting, but where symptoms persist or increase after 5 days, topical steroids may be considered to reduce the inflammatory reaction.‟

6
Bartlett JG, Gorbach SL. Anaerobic infections of the head and neck. Otolaryngol Clin North Am 1976;9:655-78. RATIONALE: Anaerobes are an unusual finding in acute upper respiratory infections such as acute rhinosinusitis and acute otitis media, but are increasingly found in chronic disease. Co-amoxiclav is active against many anaerobes as well as S. pneumoniae and H. influenzae.

7
De Ferranti SD, Lonnidis JPA, Lau J, Anniger WV, Barza M. Are amoxicillin and folate inhibitors as effective as other antibiotics for acute sinusitis? BMJ 1998 ;317: 632-7. RATIONALE: On current evidence, no one class of antibacterial is more likely than another to cure patients with sinusitis.

8
Hansen JG, Schmidt H, Grinsted P. Randomised double-blind, placebo controlled trial of penicillin V in the treatment of acute maxillary sinusitis in adults in general practice. Scan J Prim Health Care 2000; 18: 44-47. RATIONALE: This primary care study (133 patients) demonstrates that Penicillin V is more effective than placebo in the treatment of acute maxillary sinusitis, but only where there is pronounced pain.

9
Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomised trials. British Journal of Clinical Pharmacology 2009;67(2) :161-71 RATIONALE: there was no difference in the comparison of short-course (3-7 days) with long-course treatment (6-10 days). The pragmatic interpretation of this meta-analysis is that a 7 day course is optimal.

10
In severe sinusitis a 1g dose may be considered to ensure bactericidal concentrations of amoxicillin in the sinuses. Lower concentrations may encourage the stepwise form of resistance that occurs with pneumococci.

Additional reference:

Hansen JG, Hojbjerg T, Rosborg J. Symptoms and signs in culture proven acute maxillary sinusitis in general practice population. APMIS 2009; 117(10): 724-9 RATIONALE: We don't yet have robust diagnostic criteria for those patients with acute rhinosinusitis that would most benefit from antibiotics. This primary care prospective cohort study of 174 patients shows: Fever >38 degrees; maxillary toothache and raised ESR were associated with S. pneumoniae and H. influenzae positive rhino sinusitis.

The POCAST project is funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London and by the Imperial College Healthcare Charity (Grant Ref No:7006/P36U).