Authors' objectives:

This report summarizes the published evidence on the diagnosis and treatment of community-acquired acute bacterial rhinosinusitis in children and adults. The performance of diagnostic tests and the efficacy of antibiotics and ancillary treatments were assessed.

Authors' results and conclusions: Compared with sinus puncture, the reference standard for diagnosing acute bacterial rhinosinusitis, sinus radiography has moderate sensitivity (76 percent) and specificity (79 percent). Sinus ultrasonography has similar test characteristics, but the results are more variable and the procedure is not commonly used in the United States. Limited evidence suggests that diagnoses based on clinical criteria may be as accurate as those using sinus radiography. In a meta-analysis of six placebo controlled trials, antibiotics reduced the incidence of clinical failures by one-half, although about two-thirds of the patients improved by 14 days without antibiotics. The risk of clinical failure did not differ significantly between amoxicillin or folate inhibitors (e.g., trimethoprim/sulfamethoxazole) and newer, more expensive antibiotics. No serious complications from lack of treatment were reported. Some of the 10 trials assessing nonantibiotic, ancillary treatments reported statistically significant results. However, these trials included different treatments, often in conjunction with antibiotics, so further analyses were limited. To minimize symptom duration, initial symptomatic treatment is the most cost-effective strategy up to a prevalence of 25 percent, the use of clinical criteria to guide treatment is most cost-effective for a prevalence between 25 percent and 83 percent, and empirical antibiotic treatment with amoxicillin or a folate inhibitor is cost effective only above the prevalence of 83 percent. Sinus radiography-guided treatment, as an initial management strategy for uncomplicated patients, is not cost effective at any prevalence. The quality of the diagnostic and treatment trials reviewed was suboptimal. However, the results were generally consistent, sensitivity analyses showed the results to be robust, and the conclusions are consistent with the majority of expert opinions.

Authors' recommendations: In primary care, where the prevalence of bacterial infection in patients presenting with symptoms suggesting acute rhinosinusitis is low to moderate, initial symptomatic treatment or the use of clinical criteria to guide treatment is the most cost effective approach for patients with uncomplicated infections. If antibiotics are given, amoxicillin or a folate inhibitor should be considered initially, as should the severity of the symptoms. Future studies should use more rigorous diagnostic standards and clinical outcome measures. The optimal duration of antibiotic treatment, the role of patient preferences in clinical decisionmaking, and the issue of emerging antibiotic resistance also need to be addressed.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.ahrq.gov/clinic/epcsums/sinussum.htm

Year Published: 1998

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: United States

Organisation Name: Agency for Healthcare Research and Quality

Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;

Contact Name: martin.erlichman@ahrq.hhs.gov

Contact Email: martin.erlichman@ahrq.hhs.gov

Copyright: Agency for Healthcare Research and Quality (AHRQ)