Amoxicillin for Acute Rhinosinusitis Does Not Improve Symptoms at 3 Days But Reduces Likelihood of Symptoms at 7 Days

DynaMed Weekly Update - Volume 7, Issue 8

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Guidelines from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) and the Centers for Disease Control and Prevention (CDC) recommend deferring antibiotic treatment for acute bacterial rhinosinusitis for at least 7 days after diagnosis and limiting initial management to symptomatic relief. If the decision is made to treat with antibiotics, amoxicillin is the first-line therapy recommended for most adults (Otolaryngol Head Neck Surg 2007 Sep;137(3 Suppl):S1, Ann Intern Med 2001 Mar 20;134(6):479). A new randomized trial evaluated the efficacy of amoxicillin in 166 adults with acute sinusitis treated according to these guidelines.

Patients aged 18-70 years meeting the CDC diagnostic criteria for acute bacterial rhinosinusitis with symptoms for 7-28 days were randomized to amoxicillin 500 mg vs. placebo orally 3 times daily for 10 days. All patients had moderate to very severe symptoms with mean duration of 11 days. A 5-7 day supply of symptomatic treatments was given to all patients. The primary outcome was change in disease-specific quality of life measured by the SNOT-16 score (Sinonasal Outcome Test-16). The SNOT-16 score rates the severity of 16 sinus-related symptoms on a 0-3 scale, with a minimally important difference of 0.5 points. Patients also rated their overall symptoms on a scale of 0-6, ranging from no symptoms to feeling “a lot worse.”

On day 3 of treatment there were no significant differences in mean reduction in SNOT-16 score (0.59 vs. 0.54) or self-reported symptom improvement (symptoms rated as “a lot better” or no symptoms in 37% vs. 34%) (level 1 [likely reliable] evidence). On day 7, the mean SNOT-16 score was statistically improved for the amoxicillin group (mean reduction 1.06 vs. 0.86, p = 0.02) but this difference did not reach the threshold of clinical importance. However, the amoxicillin group did show clinically meaningful improvement in the proportion of patients rating themselves as a lot better or without symptoms (74% vs. 56%, p = 0.02, NNT 6). At 10 days there were no significant differences in symptoms. There were no significant differences in adverse events, days of work missed, relapse or recurrence, or satisfaction with treatment at any time point (JAMA 2012 Feb 15;307(7):685).

For more information, see the Acute sinusitis topic in DynaMed.