sinusitis

March 15, 2008

How in the world do we convince our patients (and perhaps ourselves),

that the following study describes the truth about treatment of

sinusitis?

Antibiotics, Intranasal Steroids, and Acute Bacterial Sinusitis

Clinically diagnosed patients showed no benefit with either treatment.

We lack strong evidence that antibiotics are effective in acute

bacterial sinusitis that is diagnosed clinically in primary care

settings. Nevertheless, prescribing rates of 80% or higher are

common in the U.S. and several European countries.

In this U.K. study, 240 adults with clinically diagnosed

bacterial sinusitis were randomized to receive amoxicillin (500 mg 3

times daily for 1 week) plus nasal placebo, intranasal budesonide (200

¦Ìg intranasally daily for 10 days) plus oral placebo, both active

treatments, or double placebo. Patients were required to meet at least

two of the following criteria: unilateral or bilateral purulent

rhinorrhea, unilateral sinus pain, and purulence on nasal inspection.

Patients with recurrent sinusitis or significant chronic medical

illness were excluded. Based on self-reported diaries and symptom

questionnaires at 2 weeks follow-up, none of the active treatments

were superior to placebo in symptom resolution by 10 days (roughly 70%

in all groups) or other total symptom scores.

Comment: Some previous studies have shown that antibiotics are

beneficial in radiographically confirmed sinusitis. However, the

diagnostic criteria in this trial undoubtedly allowed inclusion of

many patients with viral infections. In any case, these results are

consistent with those of previous studies showing that neither

antibiotics nor intranasal steroids are effective in acute sinusitis

diagnosed with criteria used by many primary care physicians.

¡½ L. Schwenk, MD

Published in Journal Watch General Medicine December 20, 2007

March 15, 2008

All our patients know that we don't give antibiotics until they have been sick for 10 days except under unusual situations. After a while they don't even call until day 10. The first time we do have to explain that antibiotics don't help even a little and might cause antibiotic resistance. With all the stuff about mrsa in the news most patients are understanding. However it took about 1 year of educating everybody. I usually quote the actual study by name to my patients. I think it makes it seem that I know what I'm doing. By the way when we do treat we use 1 gm of amoxicillin tid or 2 gm bid Larry Lindeman MDRoscoe Village Family Medicine2255 W. RoscoeChicago, Illinois 60618 How in the world do we convince our patients (and perhaps ourselves),that the following study describes the truth about treatment ofsinusitis?Antibiotics, Intranasal Steroids, and Acute Bacterial SinusitisClinically diagnosed patients showed no benefit with either treatment.We lack strong evidence that antibiotics are effective in acutebacterial sinusitis that is diagnosed clinically in primary caresettings. Nevertheless, prescribing rates of 80% or higher arecommon in the U.S. and several European countries.In this U.K. study, 240 adults with clinically diagnosedbacterial sinusitis were randomized to receive amoxicillin (500 mg 3times daily for 1 week) plus nasal placebo, intranasal budesonide (200Î¼g intranasally daily for 10 days) plus oral placebo, both activetreatments, or double placebo. Patients were required to meet at leasttwo of the following criteria: unilateral or bilateral purulentrhinorrhea, unilateral sinus pain, and purulence on nasal inspection.Patients with recurrent sinusitis or significant chronic medicalillness were excluded. Based on self-reported diaries and symptomquestionnaires at 2 weeks follow-up, none of the active treatmentswere superior to placebo in symptom resolution by 10 days (roughly 70%in all groups) or other total symptom scores.Comment: Some previous studies have shown that antibiotics arebeneficial in radiographically confirmed sinusitis. However, thediagnostic criteria in this trial undoubtedly allowed inclusion ofmany patients with viral infections. In any case, these results areconsistent with those of previous studies showing that neitherantibiotics nor intranasal steroids are effective in acute sinusitisdiagnosed with criteria used by many primary care physicians.â€” L. Schwenk, MDPublished in Journal Watch General Medicine December 20, 2007

March 15, 2008

" But doctor, I get this every year about this time and if I dont take

something it gets alot worse and I cant afford to miss work/am going

out of town this weekend. I know what I need. A Z pack works best. "

>

> All our patients know that we don't give antibiotics until they have been

> sick for 10 days except under unusual situations. After a while they don't

> even call until day 10. The first time we do have to explain that

> antibiotics don't help even a little and might cause antibiotic resistance.

> With all the stuff about mrsa in the news most patients are understanding.

> However it took about 1 year of educating everybody. I usually quote the

> actual study by name to my patients. I think it makes it seem that I know

> what I'm doing. By the way when we do treat we use 1 gm of amoxicillin tid

> or 2 gm bid

>

> Larry Lindeman MD

> Roscoe Village Family Medicine

> 2255 W. Roscoe

> Chicago, Illinois 60618

>

> How in the world do we convince our patients (and perhaps ourselves),

> that the following study describes the truth about treatment of

> sinusitis?

>

> Antibiotics, Intranasal Steroids, and Acute Bacterial Sinusitis

> Clinically diagnosed patients showed no benefit with either treatment.

> We lack strong evidence that antibiotics are effective in acute

> bacterial sinusitis that is diagnosed clinically in primary care

> settings. Nevertheless, prescribing rates of 80% or higher are

> common in the U.S. and several European countries.

> In this U.K. study, 240 adults with clinically diagnosed

> bacterial sinusitis were randomized to receive amoxicillin (500 mg 3

> times daily for 1 week) plus nasal placebo, intranasal budesonide (200

> ¦Ìg intranasally daily for 10 days) plus oral placebo, both active

> treatments, or double placebo. Patients were required to meet at least

> two of the following criteria: unilateral or bilateral purulent

> rhinorrhea, unilateral sinus pain, and purulence on nasal inspection.

> Patients with recurrent sinusitis or significant chronic medical

> illness were excluded. Based on self-reported diaries and symptom

> questionnaires at 2 weeks follow-up, none of the active treatments

> were superior to placebo in symptom resolution by 10 days (roughly 70%

> in all groups) or other total symptom scores.

>

> Comment: Some previous studies have shown that antibiotics are

> beneficial in radiographically confirmed sinusitis. However, the

> diagnostic criteria in this trial undoubtedly allowed inclusion of

> many patients with viral infections. In any case, these results are

> consistent with those of previous studies showing that neither

> antibiotics nor intranasal steroids are effective in acute sinusitis

> diagnosed with criteria used by many primary care physicians.

>

> ¡½ L. Schwenk, MD

>

> Published in Journal Watch General Medicine December 20, 2007

>

March 15, 2008

i used to think about and obsess over this a lot I was always wondering why SO many people came to a doctor's for the stuff i would NEVER go for. It used to be a bigger issue for me The things i have found are 1 lots of listening and empathy with NO MENTION OF THE VIRUS /BACTERIA /ANTIBX thing

2 comlpete comprehensive attention to what is bugging them with good listening " your head is killing you? You get this every winter? " 3 Only after the listening and the exam are done, do i say things like well you're right you have a sinus infection But i can't find any evidence that antibx are going to help(sometimes i throw in the expense thign and the diarrhea thing) i wish i could then i could make this go away What i can do is see if i can help you feel better

then offer sx care.THIS WORKS 90% of the time " but dr always gave me zpak " " he did ?really? Boy i wonder if things were exaclty the same when you saw him- could he have found something differnt on exam or were you sick longer? Hmmm " " How much did that cost anyway? "

THIS GETS ANOTHER FEW people to say well I was sick for three weeks then Oh that was before i quit smoking " Doesn't matter its free to me I will just go to the ER " " Boy I am sorry you are so sick! Hm. I hear what you are saying about last year. Tell you what, It's just gonna be a hassle to sit and wait int hat er waiting room why don't we do this MOst of these things get better in 7-14 days no matter what we do so how's about I cal li n a script for you to use if you get X symptoms or are still sick on X day then it will be there for you

I have had much less trouble in the l ast few years by doing this stuff though i know you Ron and i expect you must already do this stuffso perhaps you are t he only non antibx giving doc in your community then it is harder

But most of these folks are just frustrated " Virus " don't mean nothin to them.!I have been interested over the years in hearing how patietns report what we say " I wen to the er for this "

" what did the doc say/ " " He didn't say anything he didn't know " " he didn;t speak? he said he did not know what was wrong?? really? " i say " well he said it was a virus "

Somehow " a virus " or how that is communicated has come to mean the doc didn't know or did not try to helpThis stuff sounds so dumb i do not know why i am typin g it but since I started to tweak the way i do this with the antibx script given out only in occasional cases being extremely careful to realize the guy is just feeling like crap or has a boss who hounds him and wants you to fix him and doesn't know or care about antibx resisitence viruses bacteria or amoebae for that matter but that he gets heard and empathized with i do better. i dunno becasue i am sure you do that.

I would just add then when i work with t he residents they get the dx and treatment right but wheni ask the patietn what did she say you had- They do not know What she tell you to expect- they don't know So I say simply what you have is... This will last... The last thing to clear up w ill be.. here's what you can do....

If all else fails and they leave to see DR or the ER it is a very small minority oon and their problem isn;t the sinusitisSorry I b et you do all this It has just been interesting to me that i used to think about this all thetime and now i never do.

2008/3/15 :