Archive for April, 2015

Antibiotics for Sinusitis? Not So Fast

Tuesday, April 7, 2015 // Uncategorized

    Many people think that when they are blowing green mucous out of their nose that they have a sinus infection and that requires antibiotics.  That is wrong. That’s called rhino sinusitis and the evidence that antibiotics expedite recovery is scarce.  The following are the new guidelines on treating or not treating this condition, followed by an article about this from the Wall street Journal.
Guideline updates recommendations to manage adult rhinosinusitis

A new guideline updated recommendations to improve diagnosis, testing, and treatment of adult acute rhinosinusitis (ARS).

The guideline was issued by The American Academy of Otolaryngology-Head and Neck Surgery Foundation. Changes in content from the prior guideline issued in 2007 include extension of watchful waiting as an initial management strategy for uncomplicated acute bacterial rhinosinusitis (ABRS), changes in recommendations on first-line antibiotic therapy for ABRS, and new action statements on chronic rhinosinusitis (CRS) that focus on chronic conditions and modifying factors.

The recommendations include the following:

      • Diagnose ABRS when symptoms or signs such as purulent nasal drainage accompanied by nasal obstruction, facial pain/pressure/fullness, or both persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms or if symptoms or signs of ARS become worse within 10 days after an initial improvement. (Strong recommendation)
      • Do not order radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected. (Recommendation)
      • Analgesics, topical intranasal steroids, and/or nasal saline irrigation may be recommended for symptomatic relief of viral rhinosinusitis or ABRS. (Option)
      • Offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for uncomplicated ABRS. Watchful waiting should be offered only when there is assurance of follow-up such that antibiotic therapy is started if the patient’s condition fails to improve by 7 days after ABRS diagnosis or if it worsens at any time. (Recommendation)
      • If antibiotics are prescribed, use amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days for most adults. (Recommendation)
      • If the patient doesn’t improve with the initial management option by 7 days after diagnosis or worsens during initial management, reassess to confirm ABRS, exclude other causes of illness, and detect complications. If ABRS is confirmed in a patient managed with observation, then begin antibiotic therapy; if the patient was initially managed with an antibiotic, the antibiotic should be changed. (Recommendation)
      • Distinguish CRS and recurrent ARS from ABRS and other causes of sinonasal symptoms. (Recommendation)
      • Confirm CRS with objective documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or computed tomography. (Strong recommendation)
      • Assess the patient with CRS or recurrent ARS for chronic conditions that would change management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. (Recommendation)

The full guideline is available online in the April Otolaryngology-Head and Neck Surgery.


New Thinking on Sinus Infections

Waiting for an infection to go away on its own works almost as well as antibiotics

Allergies or a cold can help bring on sinusitis, which affects one in eight U.S. adults. ENLARGE
Allergies or a cold can help bring on sinusitis, which affects one in eight U.S. adults. Photo: Corbis

Sumathi Reddy
Sumathi Reddy
The Wall Street Journal

April 6, 2015 5:41 p.m. ET

Many people with spring allergies might also suffer with symptoms of another ailment—the facial pain, fever and nasal congestion that go with sinusitis.

New medical guidelines say taking antibiotics isn’t the only effective treatment for bacterial sinusitis, as is widely believed. The guidelines, from the American Academy of Otolaryngology—Head and Neck Surgery Foundation, say antibiotics fare only slightly better than waiting for the infection to go away on its own.

The foundation, part of the professional medical association of the same name, has for years recommended “watchful waiting” for people with sinusitis before they resort to antibiotics. The latest guidelines, published last week in the foundation’s journal, strengthen that recommendation, said Richard Rosenfeld, who chaired the group that devised the recommendations.

Antibiotics and watchful waiting are “both equally valid and recommended strategies for managing acute bacterial sinusitis,” said Dr. Rosenfeld, chairman of otolaryngology at SUNY Downstate Medical Center in Brooklyn. “Even if you’re really sick and have a high fever, it’s still OK to initially observe without antibiotics because all the data from more than a dozen trials don’t really show that there’s any greater benefit.”

The guidelines apply to acute sinusitis, in which symptoms last 10 days or more. Patients should then wait another seven days, for a total of 17 days, to see if the infection goes away on its own. If symptoms don’t improve, or worsen, antibiotic therapy should be started, the guidelines say.

A neti pot filled with a saline solution is used to flush out nasal passages and alleviate symptoms of sinusitis. ENLARGE
A neti pot filled with a saline solution is used to flush out nasal passages and alleviate symptoms of sinusitis. Photo: Getty Images

Patients with another form of infection, known as chronic sinusitis, which can last 12 weeks or more, need to see a doctor to confirm a diagnosis and discuss treatment. Some chronic-sinusitis patients have surgery to remove nasal polyps that can contribute to the underlying inflammation.

Dr. Rosenfeld said an analysis of randomized controlled trials found on average that about 86% of patients taking a placebo for acute bacterial sinusitis got better in one to two weeks compared with 91% of those taking antibiotics. The difference in outcomes is “statistically significant, but it really makes you question whether all these people need antibiotics,” he said.

An overuse of antibiotics can make the drugs less effective against the bacteria they are intended to treat by fostering the growth of antibiotic-resistant infections. It can also wipe out the body’s good bacteria, which help digest food and protect the body from infections, among other functions.

One in eight adults in the U.S. at some point contract sinusitis, which develops when viruses or bacteria infect the sinuses and can occur during allergy season or a cold. The tissue lining the sinus cavities swells and blocks the passages that normally drain the sinuses. Fluids accumulate, causing congestion and pressure or pain in the face.

Most cases of sinusitis begin as viral infections. If it lasts for 10 or more days without improvement, it is generally believed that a bacterial infection has set in, Dr. Rosenfeld said. Sinusitis is also considered to be bacterial if it lasts fewer than 10 days but gets worse after an initial improvement. Fewer than 2% of viral infections eventually become bacterial sinusitis, he said.

Still, studies show that doctors prescribe antibiotics for sinusitis patients about 90% of the time, said Daniel Merenstein, an associate professor of family medicine at Georgetown University Medical Center. More than one in five antibiotics prescribed to adults are for sinusitis, studies show.

“Sinusitis is one of the top reasons for antibiotics,” said Dr. Merenstein, who helped review the new guidelines before publication. “If people would follow this it would be great because it would really decrease antibiotic resistance, which is such a big problem in the United States,” he said.

Uncertainty whether a case of sinusitis is bacterial or viral often leads to doctors overprescribing antibiotics, Dr. Merenstein said. He said he is currently applying for funding to conduct a 760-person study looking at the treatment of sinusitis with antibiotics versus with neti pots, a popular saline-irrigation treatment to flush out the nasal passages. The study also will look at the effectiveness of a blood test to tell if a case is viral or bacterial, he said.

In rare cases sinusitis can spread to the eyes or brain. Experts recommend seeing a doctor if a patient has a progressive fever, worsening headache, change in vision or becomes confused.

Many sinusitis sufferers also have allergies, said Anju Peters, an associate professor of medicine in the division of allergy and immunology at Northwestern University in Chicago. About one-third of people with acute sinusitis have allergies and some 40% to 60% of those with chronic sinusitis have them. “They definitely tend to coexist,” said Dr. Peters, who helped review the new guidelines.

Still, there isn’t hard evidence to show that episodes of sinusitis are more common during allergy season, Dr. Rosenfeld said.

Doctors say there is little evidence for ways to help prevent sinusitis. One proven technique is to stop smoking, which damages the tissue that moistens and protects the airways.

The guidelines recommend treating acute sinusitis with over-the-counter pain relievers, such as acetaminophen and ibuprofen. Also recommended is irrigation of the nose with a saline solution, which thins the mucus in the nose, promotes drainage and reduces inflammation. Studies have found doing a high-volume saline irrigation of the nose once a day is effective for both acute and chronic sinusitis.

Another technique doctors suggest is using a bulb syringe to draw out fluids from the nasal passages. Nasal steroid sprays commonly used for allergies also have a small benefit and decongestant sprays, to be used for up to three days, can relieve stuffiness.

Write to Sumathi Reddy at [email protected]

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Less is Often More

Sunday, April 5, 2015 // Uncategorized

Why the Best Doctors Often Do Nothing

from the Wall Street Journal March 25,2015


H. GILBERT WELCH: Doctors worry that if they don’t do something [pick one: start a medicine/order a test/refer to a specialist], patients will be dissatisfied and go elsewhere. Doing something is a quick way to make patients feel heard, even if it is a poor substitute for actually having the time to listen. But we also feel pushed to act because many patients have been taught to believe that the good doctors can reliably fix problems by trying medications, ordering tests, and referring to specialists.

That leads to knee-jerk medicine. If your blood sugar is a little high, prescribe a pill to lower it. If you have back pain, get a CT of the spine to see what’s causing it. If you have a headache, refer to a neurologist to evaluate it (let them get the CT of the head).

Knee-jerk medicine is not good for you. More medications, more testing and more referrals quickly add up to real money–money that is increasingly, as first-dollar insurance coverage disappears, coming out of your pocket.

But the harm can be more than financial. A blood-sugar pill can make your blood-sugar low–too low. That’s not good for your heart or your brain. The CT of the spine will almost certainly find something abnormal in your back, as it does even in people without back pain. The abnormality almost certainly has nothing to do with your back pain, but may nonetheless provide a rationale for back surgery (which can have the annoying side-effect of turning acute back pain into chronic back pain). And after finding nothing abnormal in the head CT, the neurologist may suggest a neck ultrasound. While he’s checking out the blood supply to the brain, the radiologist may stumble onto a small thyroid cancer.

Now you really have a headache on your hands. And now there will be real pressure to do something (even though many adults have small thyroid cancers if we look hard enough).

Doctors can fix some problems, others are better fixed by the patient. Some problems will resolve on their own, others are better left alone (particularly those “problems” that don’t bother you). The good doctor is not the one that always recommends doing something. It’s too easy for the physician–and it’s too easy for you to get somewhere you don’t want to be.

You don’t want a knee-jerk recommendation from your financial adviser that you always need to move money around. Or a knee-jerk recommendation from your insurance agent that you always need to increase coverage. Or from your lawyer that you always need to change the will. Or from your dentist that you always need X-rays. True professionals provide considered advice. And sometimes doing nothing is exactly the right thing to do.

The same is true of medicine. Recognize that the doctor who advises no action may be the one who really cares for you.

H. Gilbert Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and professor of business administration at the Tuck School of Business. He is the author of  “Less Medicine, More Health–7 Assumptions that Drive Too Much Medical Care.”

Read the latest Health Report.

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