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Review: penicillin V is better than placebo and equal to
non-penicillins for acute maxillary sinusitis
Williams Jr JW, Aguilar C, Makela M, et al. Antimicrobial therapy for acute maxillary sinusitis. (Cochrane Review, latest
version 26 May 1999.) In: Cochrane Library. Oxford: Update Software.
QUESTION: In adults with acute maxillary sinusitis, which antibiotics lead to higher
clinical cure rates?
Data sources
Studies were identified by searching Medline and
EMBASE/Excerpta Medica (to October 1998) with the
heading sinusitis and terms for randomised controlled
trials, scanning bibliographies of relevant articles, and
contacting pharmaceutical companies and experts in
the field.
Study selection
Studies were selected if they were randomised controlled trials (RCTs) that compared an antibiotic with
placebo or another class of antibiotic in >30 patients
who were >18 years of age and had a history consistent
with acute maxillary sinusitis confirmed by radiography
or aspiration.
Data extraction
2 or more reviewers independently extracted data on
study characteristics; interventions; study duration;
length of follow up; cointerventions; compliance; and
clinical, bacteriological, radiographic, and adverse event
outcomes.
Main results
32 RCTs (7330 patients) with 34 comparisons met the
inclusion criteria. Treatment duration ranged from 3–15
days. Penicillin V led to an increase in clinical cure rate
(table). No difference in clinical cure rate was seen for
amoxicillin compared with control in 2 heterogeneous
RCTs. Newer non-penicillin antibiotics compared with
penicillin V or amoxicillin (8 RCTs), or macrolide or
cephalosporin compared with amoxicillin–clavulanate
(8 RCTs) showed no difference in clinical cure rates. 5
RCTs comparing tetracyclines with a heterogeneous
mix of antibiotics could not be meta-analysed. Dropouts
from adverse effects were fewer for macrolide or cephalosporin than for amoxicillin-clavulanate (9 RCTs)
(table).
COMMENTARY
Sinusitis accounts for 12% of the antibiotics prescribed for
adults in primary care.1 Of additional concern is the trend
toward the use of expensive, broad spectrum antibiotics,
particularly in an era of emerging antimicrobial resistance.2
The review by Williams et al provides credible evidence
that a simple inexpensive antibiotic, penicillin, is effective in
achieving a clinical cure for acute sinusitis. More importantly, this evaluation of 32 RCTs found no significant
differences in cure rates with extended spectrum antibiotics.
One broad spectrum agent, amoxicillin-clavulanate, had
higher treatment attrition because of side effects. Interestingly, 1 study referenced by Williams found no benefit for
the use of antibiotics in acute sinusitis.
One limitation of this review is the small number of studies that documented radiographic outcomes of sinusitis
management plans. Sinusitis relapse rates are also a topic for
additional inquiry because only 1 placebo controlled
antibiotic trial reported this information. The authors
recommend large controlled trials to determine clinical
indicators for antibiotic use and clinical outcomes associated
with particular antibiotics.
Consumer demand for antibiotics and provider prescribing practices have been implicated in the emergence of antimicrobial resistance.1 Williams et al’s findings, the result of an
exhaustive review of published and unpublished sources,
should prompt clinicians to revisit the use of penicillin in
acute sinusitis. Nurses in primary care have a unique opportunity to reduce the financial and public health costs associated with indiscriminate antibiotic use, firstly by educating
patients away from the use of antibiotics in early upper respiratory infection, and, secondly, by reassuring patients that
penicillin is an effective first line agent for sinusitis if an antibiotic is warranted.
Source of funding: no
external funding.
For correspondence:
Dr J W Williams Jr,
South Texas Veterans
Health Care System,
Audie Murphy Division,
7400 Merton Minter
Boulevard, San Antonio,
TX 78284, USA.
Tammy Anderer, CRNP, MSN
Family Nurse Practitioner and Nursing Faculty
The Geisinger Health System and Lycoming College
Williamsport, Pennsylvania, USA
1
2
A modified version of this
abstract appears in ACP
Journal Club and
Evidence-Based
Medicine.
Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for
adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901–4.
Reece SM. The emerging threat of antimicrobial resistance:
strategies for change. Nurse Pract 1999;24(11):70–80.
Antibiotics v placebo or other antibiotics for acute maxillary sinusitis*
Conclusion
In adults with acute maxillary sinusitis, penicillin V is
better than placebo and equal to non-penicillins for
achieving clinical cure.
Outcomes
Comparison
(no. of RCTs)
Weighted
event rates
Clinical cure rate
Penicillin v control (2)
35% v 19%
RBI (95% CI)
NNT (CI)
72% (0 to 196)
7 (4 to 39)
RRR (CI)
Dropouts from
adverse events
Macrolide/
cephalosporin v
amoxicillinclavulanate (9)
2% v 4%
56% (22 to 75)
44 (25 to 200)
*RCTs=randomised controlled trials. Other abbreviations defined in glossary; RRR, RBI, NNT, and CI calculated
from data in article.
Treatment
EBN Volume 3 April 2000 49
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Review: penicillin V is better than placebo and
equal to non-penicillins for acute maxillary
sinusitis
Evid Based Nurs 2000 3: 49
doi: 10.1136/ebn.3.2.49
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