The study, conducted by researchers at Washington University School
of Medicine in St. Louis and Express Scripts Inc., appears in the
Oct. 17, 2001 issue of the Journal of the American Medical Association.
"Our findings suggest that doctors should keep it simple
when treating adults for acute, uncomplicated sinusitis," says
Jay F. Piccirillo, M.D., associate professor of otolaryngology
and lead author of the study. Express Scripts Inc., a St. Louis-based
pharmacy benefit management firm, provided the data for the study.
Acute sinusitis is an infection and inflammation of the paranasal
sinuses (those above, below and on either side of the nose) of
four weeks duration or less. About 35 million people in the United
States are affected by sinusitis each year generating almost
3 million office visits.
In this study, researchers examined data from 29,102 adults who
received initial antibiotic treatment for acute, uncomplicated
sinusitis between July 1, 1996, and June 30, 1997.
Research Results on Antibiotic Treatment
The team found that 17 different antibiotics had been prescribed
to sinusitis patients. These antibiotics were categorized as
first-line or second-line. First-line antibiotics, such as amoxicillin,
co-trimoxazole and erythromycin, generally are recommended for
initial treatment of an infection. Second-line antibiotics, such
as clarithromycin and amoxicillin-clavulanate, are intended for
patients who are not helped by or cannot tolerate first-line
drugs. First-line antibiotics typically are older and less expensive
than second-line drugs. Second-line drugs also target a wider
range of bacteria than first-line drugs.
The study revealed that 60 percent of all patients in the database
had received first-line antibiotics, while 40 percent had received
second-line therapy. Primary-care physicians prescribed first-line
antibiotics 60 percent of the time, while specialists prescribed
second-line antibiotics 63 percent of the time.
The researchers deemed treatment to be successful if the patient
did not require additional antibiotics for 28 days following initial
treatment. Those patients who received first-line antibiotics had
a 90.1 percent success rate, while those who received second-line
drugs had a 90.8 percent success rate.
"A 0.7 percent difference between the two groups is too small
to be clinically significant," says Piccirillo, who also is
director of the Clinical Outcomes Research Office in the Department
of Otolaryngology. "Essentially, the two types of antibiotics
were equally successful."
Antibiotic Cost Differs for Sinusitis Treatment
But while the effectiveness of the two groups of drugs was nearly
identical, their cost was strikingly different. Charges for patients
who received first-line antibiotics were, on average, $68.98,
while charges for those given second-line antibiotics were $135.17,
a difference of $66.19.
"By showing that cost is the only difference between first-
and second-line antibiotics in the treatment of acute, uncomplicated
sinusitis, this study validates nationally accepted practice guidelines
recommending initial use of first-line over second-line antibiotics," says
Mark Frisse, M.D., chief medical officer of Express Scripts and
a coauthor of the study.
Initial treatment of the disorder is further complicated by the
fact that sinusitis usually begins as a viral infection. Antibiotics
should be used to treat bacterial infections; indiscriminate use
of antibiotics has contributed to the emergence and spread of antibiotic-resistant
"Because of this problem," says Piccirillo, "patients
with signs and symptoms of acute, uncomplicated sinusitis should
be treated only with a decongestant for the first three to five
Most viral infections run their course in seven
to 10 days, he says. "After about five days, a person with
a viral infection should begin feeling better. If, on the other
hand, their nasal
discharge becomes more colored--yellow or green--and they are in
more pain, then a course of antibiotics is appropriate."