How should we treat acute maxillary sinusitis?

Objectives. Among adults seeking care in ambulatory practices, sinusitis is the most common diagnosis treated with antibiotics. The objective of this review was to see whether antibiotics are indicated for treatment of acute sinusitis and, if so, which antibiotic classes are most effective. Search Strategy. Relevant studies were identified from searches of Medline and Embase in October 1998, contacts with pharmaceutical companies and bibl iographies of included studies. Selection Criteria, Randomized trials that compared antibiotic with control or antibiotics from different classes in the treatment of acute maxillary sinusitis were eligible, Additional criteria were diagnostic confirmation b y radiograph or sinus aspiration, outcomes that included clinical cure or i mprovement, and a sample size of 30 or more adults, Of 1,784 potentially re levant studies, two or more reviewers identified 32 studies that met select ion criteria. Data Collection and Analysis. Data were abstracted independently by two per sons and synthesized descriptively. Some data were analyzed quantitatively using a random effects model. Primary outcomes were (A) clinical cure and ( B) clinical cure or improvement. Secondary outcomes were radiographic impro vement, relapse rates and dropouts related to adverse effects. Primary Results. Thirty-two trials involving 7,330 subjects evaluated antib iotic treatment for acute maxillary sinusitis. Major comparisons were antib iotic versus control (n = 5); newer, nonpenicillin antibiotic versus penici llin class (n = 10); and amoxicillin-clavulanate versus other extended-spec trum antibiotics (n = 10). Most trials were conducted in otolaryngology set tings. Only five trials described adequate allocation and concealment proce dures; 10 were double blind. Compared to control, penicillin improved clini cal cures (relative risk [RR] 1.72, 95 percent confidence interval [Cl] 1.0 0 to 2.96). Treatment with amoxicillin did not significantly improve cure r ates (RR 2.06; 95 percent Cl 0.65 to 6.53), but there was significant varia bility between studies. Radiographic outcomes were improved by antibiotic t reatment. Comparisons between classes of antibiotics showed no significant differences: newer nonpenicillins versus penicillins (RR for cure 1.07; 95 percent Cl 0.99 to 1.17); newer nonpenicillins versus amoxicillin-clavulana te (RR for cure 1.01, 95 percent Cl 0.97 to 1,04). Dropouts related to adve rse effects were significantly lower among those taking cephalosporin antib iotics when compared to those taking amoxicillin-clavulanate. Relapse rates within one month of successful therapy were 5 percent. Reviewers' Conclusions. For acute maxillary sinusitis confirmed radiographi cally or by aspiration, current evidence, although limited, supports penici llin or amoxicillin therapy for seven to 14 days. Clinicians should weigh t he moderate benefits of antibiotic treatment against the potential for adve rse effects.