Predicting prognosis and effect of antibiotic treatment in rhinosinusitis

Abstract

Purpose: In evaluating complaints suggestive of rhinosinusitis, family physicians have to rely chiefly on the findings of a history, a physical examination, and plain radiographs. Yet, evidence of the value of signs, symptoms, or radiographs in the management of these patients is sparse. We aimed to determine whether clinical signs and symptoms or radiographic findings can predict the duration of the illness, the effect of antibiotic treatment, or both.

Methods: We analyzed data from 300 patients with rhinosinusitis-like complaints participating in a randomized controlled trial comparing amoxicillin with placebo. We used Cox regression analysis to assess the association between the presence at baseline of rhinosinusitis signs and symptoms or an abnormal radiograph and the subsequent course of the illness. We then tested for interactions to assess whether the presence of any of these findings predicted a beneficial effect of antibiotic treatment.

Results: Two factors at baseline were independently associated with a prolonged course of the illness: a general feeling of illness (hazard ratio = 0.77, 95% confidence interval, 0.60-0.99) and reduced productivity (hazard ratio = 0.68, 95% confidence interval, 0.53-0.88). Neither typical sinusitis signs and symptoms nor abnormal radiographs had any prognostic value. Prognosis remained unchanged whether or not patients were treated with antibiotics, no matter what symptoms patients had at baseline.

Conclusions: In a large group of average patients with rhinosinusitis, neither the presence of typical signs or symptoms nor an abnormal radiograph provided information with regard to the prognosis or the effect of amoxicillin. The time to recovery was longer in patients who felt ill at baseline or who did not feel able to work, but the course of their illness was not influenced by antibiotic treatment.

Figure 1.

Flow chart of patients studied.

Figure 2.

Recovery of patients according to their general feeling of illness at baseline adjusted for covariates. FP = family physician. Hazard ratio = 0.68 (95% confidence interval, 0.53–0.88); P = .003.

Figure 3.

Illness course in patients according to treatment and clinical sum score. FP = family physician. Note: For the sum score, 1 point was given for each of the following: purulent rhinorrhea, postnasal drip, temperature ≤37.5°C, complaints present for ≤7 days, biphasic illness history, pain on bending, unilateral facial pain, and pain in upper teeth. Possible range of scores: 0 to 8 points. * Cox regression analysis for interaction between clinical sum score and treatment group (see also Table 3 ▶). Model: clinical sum score (<4 /≤4) + treatment group (amoxicillin/placebo) + clinical sum score × treatment group. P value for interaction = .36.

Figure 4.

Illness course in patients according to treatment and general feeling of illness. FP = family physician. * Cox regression analysis for interaction between general feeling and treatment group (see also Table 3 ▶). Model: general feeling of illness (present vs absent) + treatment group (amoxicillin vs placebo) + general feeling of illness × treatment group. P value for interaction = .91.