At many a doctor’s visit, there is often an expectation that the patient goes home with a pill to “fix” the problem. It represents a tangible reminder that the physician has done something — anything — to address the presenting need. There are many scenarios where the use of medication can be easily justified (e.g., high cholesterol, uncontrolled diabetes, hypertension). There are also scenarios where prescribing a pharmacologic agent may be more controversial, such as whether to use of antibiotics or steroids in sinus infections.

In light of growing bacterial drug resistance, and the lag in development of novel antibiotics, there are good reasons to take a conservative approach to prescription writing. Moreover, since current antibiotics predominantly target bacteria and not viruses, the need for antibiotics in infections that are typically viral becomes unclear. Do you empirically treat an infection with drugs or allow the body’s immune system to clear the pathogen on its own?

A randomized controlled study recently performed in the UK tries to address the question of whether antibiotics and/or steroids are beneficial in acute sinusitis. Between 2001 to 2005, 240 adults with
new onset, non-recurrent sinusitis were randomly divided into four groups: treatment with antibiotics (amoxicillin) and nasal steroids (budesonide); placebo antibiotic and steroids; antibiotics and placebo
steroids; and double placebo. The study found that 29% of patients given antibiotics vs. 33.6% without antibiotics experienced symptoms for 10 days or longer. The comparison between steroid and no-steroid use
showed an identical proportion of patients (31.4%) in both groups with symptoms 10 days or longer. The differences are noted to be insignificant.

The authors’ conclusion? . . .

among patients with the typical features of acute bacterial sinusitis, neither an antibiotic nor a topical steroid alone or in combination are effective in altering the symptom severity, the duration, or the natural history of the condition.

Although the small sample size is a limitation of the study, this is purportedly the largest non-pharmaceutically funded study to address the question. Another limitation of the study includes a lack of differentiation between bacterial or viral infections. As mentioned earlier, most viral infections do not typically respond to our current armamentarium of antibiotics.

More research is necessary to validate the results and conclusions. They nevertheless illustrate a point that sometimes no medicine is the best medicine. Of course, there are many more times when directed pharmacologic therapy is vital for a good outcome. But, I would best leave it to the doctor to decide.

• Source
• Williamson IG, Rumsby K, Benge S, Moore M, Smith PW, Cross M, Little P. Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: a randomized controlled trial. JAMA 2007;298:2487-96.