BMJ 1998;317:632-637 ( 5 September )

General Practice

Are amoxycillin and folate inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis

Sarah D de Ferranti, research associate, a John P A Ioannidis, research fellow, b Joseph Lau, associate professor, a William V Anninger, research assistant, a Michael Barza, professor. b

a Division of Clinical Care Research, Department of Medicine, New England Medical Center, 750 Washington Street, Boston, MA 02111, USA, b Division of Geographic Medicine and Infectious Diseases, Tupper Research Institute, Department of Medicine, New England Medical Center, Boston

Correspondence to: Dr Lau joseph.lau{at}es.nemc.org

Objectives: To examine whether antibiotics are indicated in treating uncomplicated acute sinusitis and, if so, whether newer and more expensive antibiotics with broad spectra of antimicrobial activity are more effective than amoxycillin or folate inhibitors.
Design: Meta-analysis of randomised trials.
Setting: Outpatient clinics.
Subjects: 2717 patients with acute sinusitis or acute exacerbation of chronic sinusitis from 27 trials.
Interventions: Any antibiotic versus placebo; amoxycillin or folate inhibitors versus newer, more expensive antibiotics.
Main outcome measurements: Clinical failures and cures.
Results: Compared with placebo, antibiotics decreased the incidence of clinical failures by half (risk ratio 0.54 (95% confidence interval 0.37 to 0.79)). Risk of clinical failure among 1553 randomised patients was not meaningfully decreased with more expensive antibiotics as compared with amoxycillin (risk ratio 0.86 (0.62 to 1.19); risk difference 0.9 fewer failures per 100 patients (1.4 more failures to 3.1 fewer failures per 100 patients)). The results were similar for other antibiotics versus folate inhibitors (risk ratio 1.01 (0.52 to 1.97)), but data were sparse (n=410) and of low quality.
Conclusions: Amoxycillin and folate inhibitors are essentially as effective as more expensive antibiotics for the initial treatment of uncomplicated acute sinusitis. Small differences in efficacy may exist, but are unlikely to be clinically important.

Key messages

  • A major question in managing acute sinusitis is whether antibiotics should be used, and if so which drugs should be chosen

  • In a comprehensive meta-analysis we evaluated evidence from randomised controlled trials comparing, firstly, antibiotics against placebo and, secondly, amoxycillin and folate inhibitors against newer, more expensive antibiotics

  • Antibiotics were significantly more efficacious than placebo in achieving cure of clinical symptoms, but over two thirds of placebo patients showed spontaneous resolution or improvement of symptoms

  • Amoxycillin and folate inhibitors had overall similar efficacy compared with newer antibiotics

  • The current evidence does not justify the use of expensive, broad spectrum antibiotics in the community for treating uncomplicated acute sinusitis



© BMJ 1998
Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to StumbleUpon StumbleUpon   Add to Technorati Technorati    What's this?

Relevant Articles

Antibiotics for acute sinusitis in general practice
G G Browning, John P A Ioannidis, Sarah D de Ferranti, Michael Barza, and Joseph Lau
BMJ 1999 318: 1623. [Extract] [Full Text]

Amoxycillin and folate inhibitors are as effective as newer antibiotics in acute sinusitis
BMJ 1998 317: 0. [Full Text]

This article has been cited by other articles:

  • Hwang, P. H. (2009). A 51-Year-Old Woman With Acute Onset of Facial Pressure, Rhinorrhea, and Tooth Pain: Review of Acute Rhinosinusitis. JAMA 301: 1798-1807 [Abstract] [Full text]  
  • McQuillan, L., Crane, L. A., Kempe, A. (2009). Diagnosis and Management of Acute Sinusitis by Pediatricians. Pediatrics 123: e193-e198 [Abstract] [Full text]  
  • Williamson, I. G., Rumsby, K., Benge, S., Moore, M., Smith, P. W., Cross, M., Little, P. (2007). Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis: A Randomized Controlled Trial. JAMA 298: 2487-2496 [Abstract] [Full text]  
  • Takemura, Y, Ebisawa, K, Kakoi, H, Saitoh, H, Kure, H, Ishida, H, Kure, M (2005). Antibiotic selection patterns in acutely febrile new outpatients with or without immediate testing for C reactive protein and leucocyte count. J. Clin. Pathol. 58: 729-733 [Abstract] [Full text]  
  • Zintzaras, E., Ioannidis, J. P. A. (2003). Modelling of escalating outpatient antibiotic expenditures. J Antimicrob Chemother 52: 1001-1004 [Abstract] [Full text]  
  • Leibovici, L., Soares-Weiser, K., Paul, M., Goldberg, E., Herxheimer, A., Garner, P. (2003). Considering resistance in systematic reviews of antibiotic treatment. J Antimicrob Chemother 52: 564-571 [Abstract] [Full text]  
  • Bucher, H. C., Tschudi, P., Young, J., Periat, P., Welge-Lussen, A., Zust, H., Schindler, C. (2003). Effect of Amoxicillin-Clavulanate in Clinically Diagnosed Acute Rhinosinusitis: A Placebo-Controlled, Double-blind, Randomized Trial in General Practice. Arch Intern Med 163: 1793-1798 [Abstract] [Full text]  
  • Werning, J. W., Preston, T. W., Khuder, S. (2002). Physician Specialty Is Associated With Differences in the Evaluation and Management of Acute Bacterial Rhinosinusitis. Arch Otolaryngol Head Neck Surg 128: 123-130 [Abstract] [Full text]  
  • Ioannidis, J. P.A., Contopoulos-Ioannidis, D. G., Chew, P., Lau, J. (2001). Meta-analysis of randomized controlled trials on the comparative efficacy and safety of azithromycin against other antibiotics for upper respiratory tract infections. J Antimicrob Chemother 48: 677-689 [Abstract] [Full text]  
  • Piccirillo, J. F., Mager, D. E., Frisse, M. E., Brophy, R. H., Goggin, A. (2001). Impact of First-Line vs Second-Line Antibiotics for the Treatment of Acute Uncomplicated Sinusitis. JAMA 286: 1849-1856 [Abstract] [Full text]  
  • Ioannidis, J. P. A., Lau, J. (2001). Technical Report: Evidence for the Diagnosis and Treatment of Acute Uncomplicated Sinusitis in Children: A Systematic Overview. Pediatrics 108: e57-57 [Abstract] [Full text]  
  • Garbutt, J. M., Goldstein, M., Gellman, E., Shannon, W., Littenberg, B. (2001). A Randomized, Placebo-Controlled Trial of Antimicrobial Treatment for Children With Clinically Diagnosed Acute Sinusitis. Pediatrics 107: 619-625 [Abstract] [Full text]  
  • Little, P., Gould, C., Williamson, I., Moore, M., Warner, G., Dunleavey, J. (2001). Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. BMJ 322: 336-342 [Abstract] [Full text]  
  • Turnidge, J. D. (2000). Quantifying the impact of resistance for prescribers and drug developers--a function of natural resolution rates. J Antimicrob Chemother 45: 925-926 [Full text]  
  • Browning, G G, Ioannidis, J. P A, de Ferranti, S. D, Barza, M., Lau, J. (1999). Antibiotics for acute sinusitis in general practice. BMJ 318: 1623-1623 [Full text]  

Rapid Responses:

Read all Rapid Responses

Wrong test of heterogeneity used?
Marjolein Y Berger
bmj.com, 23 Oct 1998 [Full text]
PLEASE, no more relative risks/odds ratios/risk ratios!
Yogi Sehgal
bmj.com, 12 Nov 1998 [Full text]
Antibiotics for acute sinusitis in general practice
G G Browning
bmj.com, 27 Nov 1998 [Full text]
Access jobs at BMJ Careers
Whats new online at Student BMJ