Correspondence

Sinusitis

N Engl J Med 2005; 352:203-204January 13, 2005

Article

To the Editor:

Piccirillo (Aug. 26 issue)1 recommends that acute bacterial sinusitis be treated with 500 mg of amoxicillin three times daily. Pneumococcus is an important cause of this condition and, at present, 40 percent of pneumococci in the United States have reduced susceptibility to penicillin.2

This reduced susceptibility has prompted physicians to recommend amoxicillin, 90 mg per kilogram of body weight per day in divided doses, to treat otitis media,3 and daily doses of amoxicillin ranging from 1.5 to 4 g daily for treating acute bacterial sinusitis in adults.4 For sinusitis, the lower dosage is recommended in geographic areas with a low prevalence of antibiotic-resistant pneumococci, and for patients with mild disease.4 However, almost no area in the United States has less than 25 percent resistance among pneumococci.2

Given the high rate of spontaneous resolution of symptoms associated with sinusitis, on the one hand, and the cost (financial and otherwise) of failed therapy, on the other, it seems reasonable to be conservative about deciding to use antimicrobial agents5 — for example, by not treating mild cases, but then prescribing higher doses of amoxicillin, such as 1 g three to four times daily, if one chooses to treat.

Daniel Musher, M.D.
Veterans Affairs Medical Center, Houston, TX 77030
daniel.musher@med.va.gov

Rebecca Musher Gross, M.D.
Potomac Physician Associates, Kensington, MD 20895

5 References

1. 1

   Piccirillo JF. Acute bacterial sinusitis. N Engl J Med 2004;351:902-910
   Full Text | Web of Science | Medline

2. 2

   Gordon KA, Biedenbach DJ, Jones RN. Comparison of Streptococcus pneumoniae and Haemophilus influenzae susceptibilities from community-acquired respiratory tract infections and hospitalized patients with pneumonia: five-year results for the SENTRY Antimicrobial Surveillance Program. Diagn Microbiol Infect Dis 2003;46:285-289
   CrossRef | Web of Science | Medline

3. 3

   Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance -- a report from the Drug-resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J 1999;18:1-9[Erratum, Pediatr Infect Dis J 1999;18:341.]
   CrossRef | Web of Science | Medline

4. 4

   Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004;130:Suppl:1-45[Erratum, Otolaryngol Head Neck Surg 2004;130:794-6.]
   Web of Science | Medline

5. 5

   Snow V, Mottur-Pilson C, Hickner JM. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Intern Med 2001;134:495-497
   Web of Science | Medline

To the Editor:

Piccirillo's recommendations for antibiotic treatment for bacterial sinusitis are not based on appropriate methods or current microbiologic data and are not consistent with recent guidelines.1,2 Many of the studies cited to support his recommendations were of small patient populations and were published before resistance developed in the bacterial pathogens. The current guidelines of the Sinus and Allergy Health Partnership1 do not support the use of doxycycline and trimethoprim–sulfamethoxazole as reasonable first-line options, nor do they support some of the recommended antibiotic agents for patients who have not improved after 72 hours; respiratory fluoroquinolones and high-dose amoxicillin–clavulanate are appropriate, but azithromycin is considered a poor choice for second-line treatment because of the intrinsic resistance of Haemophilus influenzae and the 30 percent rate of resistance in Streptococcus pneumoniae.1 Contemporary recommendations for antibiotic use in bacterial rhinosinusitis should be based on the probability of bacterial disease, the susceptibility of pathogens, the spontaneous-resolution rates, the risk-to-benefit ratios of various antimicrobial agents against the prevalent organisms, and pharmacokinetic and pharmacodynamic principles.2

Jack B. Anon, M.D.
University of Pittsburgh School of Medicine, Erie, PA 16508
janonmd@velocity.net

Michael D. Poole, M.D., Ph.D.
University of Texas at Houston Medical School, Houston, TX 77030

Michael R. Jacobs, M.D., Ph.D.
Case Western Reserve Medical School, Cleveland, OH 44106

2 References

1. 1

   Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004;130:Suppl:1-45[Erratum, Otolaryngol Head Neck Surg 2004;130:794-6.]
   Web of Science | Medline

2. 2

   American Academy of Pediatrics, Subcommittee on Management of Sinusitis. Clinical practice guideline: management of sinusitis. Pediatrics 2001;108:798-808[Erratum, Pediatrics 2001;108:A24, 2002;109:40.]
   Web of Science | Medline

Author/Editor Response

I appreciate the comments of Drs. Musher and Gross regarding the use of higher doses of amoxicillin when choosing to treat acute bacterial sinusitis.

It should be noted that telithromycin (Ketek) was approved by the Food and Drug Administration (FDA) for the treatment of acute bacterial rhinosinusitis in April 2004 and was widely available by August 1, 2004.

I disagree with Dr. Anon and colleagues that the recommendations in my Clinical Practice article were “not based on appropriate methods or current microbiologic data” and were not consistent with recently developed guidelines.1,2 In preparation for this review, a thorough search of the published medical literature was performed and all relevant articles of sufficient methodologic quality were evaluated. Antibiotic recommendations were obtained from the FDA, the Centers for Disease Control and Prevention (CDC), the Cochrane Database, and the Clinical Practice Guidelines of the American College of Physicians (ACP). The ACP guidelines were endorsed by the CDC, the American Academy of Family Physicians, the American College of Physicians–American Society of Internal Medicine, and the Infectious Diseases Society of America. The Sinus and Allergy Health Partnership1 is supported by generous contributions from several pharmaceutical companies, as detailed on its Web site (www.sahp.org/sponsorship.html). As a result, I elected not to include recommendations based on its guidelines. The guidelines developed by the Subcommittee on Management of Sinusitis and Committee on Quality Improvement of the American Academy of Pediatrics2 were developed for patients from 1 to 21 years of age. I did not include these guidelines because I do not think they are generalizable to adults.

Jay F. Piccirillo, M.D.
Washington University School of Medicine, St. Louis, MO 63110
piccirij@msnotes.wustl.edu

2 References

1. 1

   Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004;130:Suppl:1-45[Erratum, Otolaryngol Head Neck Surg 2004;130:794-6.]
   Web of Science | Medline

2. 2

   American Academy of Pediatrics, Subcommittee on Management of Sinusitis. Clinical practice guideline: management of sinusitis. Pediatrics 2001;108:798-808[Erratum, Pediatrics 2001;108:A24, 2002;109:40.]
   Web of Science | Medline