In this article, the evidence suppo...

In this article, the evidence supporting different treatments for acute bacterial rhinosinusitis (ABRS) is reviewed. In part single in kind (1) of this two-part article, clinical criteria for evaluating ABRS are described.

Antibiotics

About sum of two units thirds of patients with ABRS improve without antibiotic treatment, and in the greatest degree patients with viral upper respiratory infection (URI) improve within seven days. (2) Antibiotic therapy should be reserv for patients who have had symptoms for more than seven days and who near with two or more clinical criteria for ABRS (purulent nasal discharge, maxillary tooth or facial pain [especially unilateral], unilateral maxillary sinus tendernes or worsening symptoms after initial improvement), or for those with bitter symptoms (3) (Figure 1).

[FIGURE 1 OMITTED]

flows OF CLINICAL TRIALS

There have been no randomized controll trials (RCTs) of antibiotic treatment for ABRS using sinus aspirate improvements before and after treatment, although nonrandomized trials have demonstrated bacteriologic correctives Five RCTs and two meta-analyses have compared antibiotics, usually amoxicillin and trimethoprim-sulfamethoxazole (TMP-SMX; Bactrim, Septra), with placebo, with clinical improvement as the issue which is the more clinically relevant patient-oriented issue (4,5) About 47 percent of patients treated with antibiotics and 32 percent of the regulate group were cured at 10 to 14 days. Eighty-one percent of patients treated with antibiotics and 66 percent of the have the direction of group were cured or improved, meaning single patient benefited for every seven treated with antibiotics. The treatment power in these trials may have been underestimated because the lack of specificity of diagnosis diluted the consequence of treatment.

Amoxicillin-clavulanate potassium (Augmentin), cephalosporins (cefuroxime [Ceftin] and cefixime [Suprax]), and macrolides (azithromycin [Zithromax] and clarithromycin [Biaxin]), have been studied extensively. (67) All have demonstrated similar clinical succes rates--generally above 85 percent The use of fluoroquinolones for ABRS is relatively of the present day Ciprofloxacin (Cipro) and cefuroxime had 90 percent resolution rates when administered to patients in a primary care setting. (8) In an open-label RCT levofloxacin (Levaquin) and clarithromycin had 96 and 93 percent clinical succes rates, respectively. (9)

Four meta-analyses published within the past seven years conclud that newer broad-spectrum antibiotics are no more effective than narrow-spectrum antibiotics. (451011) In greatest in quantity of these studies, amoxicillin was compared with a cephalosporin, a fluoroquinolone, or a macrolide. The rapid emerging see the verb of antibiotic-resistant organisms associated with ABRS has made choosing an antibiotic more difficult. Surveillance studies have shown an increasing prevalence of antibiotic-resistant Streptococcus pneumoniae. (1213) Up to 25 percent of these bacteria are penicillin resistant, and 15 percent are penicillin intermediate. Resistance to macrolides, doxycycline (Vibramycin), and TMP-SMX is frequent (12) The prevalence of beta-lactamase-producing Haemophilus influenzae is about 30 percent and resistance to TMP-SMX is used by all (12) Nearly all Mycobacterium catarrhalis isolates give rise to beta-lactamase.

SELECTING AN ANTIBIOTIC

To integrate circulating antibiotic resistance surveillance data into antibiotic recommendations, the Sinus and Allergy Health Partnership (SAHP) used the Poole Therapeutic issues Model, a mathematical model that predicts clinical efficacy for each of the antibiotics commonly prescribed for ABRS (Table 1) (13-16) The gauge incorporates assumptions about the probability of bacterial infection, pathogen distribution, spontaneous resolution rates, and in vitro activity of antibiotics. (15)

When choosing antibiotic therapy for ABRS, physicians should consider novel antibiotic use, efficacy, and price The SAHP guidelines classify patients with ABRS into brace groups to determine initial treatment: (1) those with mild symptoms who have not received antibiotics within six weeks and (2) those who have moderately unrelenting disease or have received antibiotics within six weeks. (16) Patients with moderate disease are considered les likely to have spontaneous resolution and thus have a higher rate of treatment failure. The guidelines furnish no criteria for severity. The categorization of moderate or mild severity is left to the physician's clinical conclusion but an example was proffered with earlier recommendations that emphasized the inflammatory signs of febrile disease and tenderness. (17)

Although lacking finished H. influenzae coverage, amoxicillin is still a pious choice for a first-line antibiotic in community-acquired ABRS because many infections with resistant organisms improve anyway,18 and because it is well tolerated and inexpensive (Table 1) (13-16) Higher daily doses of amoxicillin (3 to 4 g through day) may be necessary in areas with a high prevalence of penicillin-resistant s pneumoniae. TMP-SMX and doxycycline are alternatives for use in patients who are allergic to beta lactams, if it be not that they have limited coverage for H influenzae and s pneumoniae, and failure rates of up to 25 percent are possible.16 Erythromycin, second-generation cephalosporins with les activity against H influenzae (eg cefaclor [Ceclor], cefprozil [Cefzil], loracarbef [Lorabid]), and tetracycline should not be used to treat ABRS. (19)