ST. LOUIS—Older antibiotics are just as good as newer drugs for managing acute sinusitis, a large retrospective cohort study suggests.[1] The older drugs have traditionally been considered first-line therapy for the condition, but their efficacy in comparison to that of newer antibiotics has not been clear. The new study answers this question: “Acute sinusitis outcomes were the same with both types of antibiotics, but second-line therapy was more expensive,” lead investigator Jay F. Piccirillo, MD, told PULMONARY REVIEWS.

Indeed, first- and second-line therapies had virtually the same rates of success (90.1% and 90.8%, respectively) and complications (one case each of periorbital cellulitis). However, per-patient costs averaged $18.19 for first-line drugs, and $81.21 for second-line agents, said Dr. Piccirillo, an Associate Professor of Otolaryngology, Head and Neck Surgery at Washington University School of Medicine in St. Louis.

Using the Express Scripts Patient Treatment Episode registry (a database of medical information from more than two million health maintenance organization members), the investigators identified 29,102 adults who had had an office visit for acute sinusitis during a recent 12-month period. To be included in the study, all patients had to have received a prescription for an antibiotic during the office visit.

Because of the study’s nature, the investigators had to assess therapeutic efficacy indirectly. They defined treatment success as the lack of a claim for an additional antibiotic in the 28 days after the office visit; treatment failure was defined as the opposite. The investigators’ cost estimates included charges both for antibiotics and for sinusitis-related medical services during the 28-day follow-up.

EQUAL EFFICACY, LOWER COST

Most patients—59.5%—received a first-line antibiotic, usually amoxicillin or trimethoprim-sulfamethoxazole. Clarithromycin, azithromycin, and amoxicillin/clavulanate were the most commonly prescribed second-line agents. Surprisingly, a third of the patients received antibiotics not approved by the Food and Drug Administration for the treatment of sinusitis.

Primary care physicians were more likely to treat acute sinusitis with first-line antibiotics. In contrast, specialists tended to prescribe second-line drugs.

Because the difference in success rates was so small, the authors estimated that 131 patients would need to be treated with second-line antibiotics to achieve one additional cure. The cost of this one additional cure would be $8,737, they calculated. This high cost was due entirely to the price of second-line agents, since charges for other services were comparable in the two groups.

Because of the higher cost and potential for bacterial resistance, the investigators concluded that physicians should avoid prescribing second-line antibiotics for initial treatment of uncomplicated acute sinusitis. “But before prescribing an antibiotic, it is important to first assess the type and duration of symptoms,” Dr. Piccirillo stressed. “If it has been a very short time and there are viral symptoms, such as watery eyes and clear, runny nasal discharge, just give the patient a decongestant.”

—Timothy Begany

Reference
1. Piccirillo JF, Mager DE, Frisse ME, et al. Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis. JAMA. 2001;286:1849-1856.

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