Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials

Abstract

What is already known about this subject: Treatment guidelines generally support that a 10-14-day antibiotic regimen should be administered to uncomplicated acute bacterial sinusitis patients. However, the level of evidence for such a recommendation is rather weak. Treatment of such duration may have disadvantages compared with a shorter duration but equally effective regimen, including the promotion of bacterial drug resistance, poorest patient compliance, higher toxicity, and a greater overall economic burden.

What this study adds: The findings of this meta-analysis suggest that short-course antibiotic treatment has similar effectiveness to longer-course treatment for patients with acute uncomplicated bacterial sinusitis, when treatment is warranted. However, we should underscore the importance of the clinician's own assessment, so that antimicrobial therapy should not inappropriately be curtailed in a patient not adequately responding to the regimen administered. We sought to evaluate the effectiveness and safety of short-course antibiotic treatment for acute bacterial sinusitis (ABS) compared with longer duration treatment. We performed a meta-analysis of randomized controlled trials (RCTs), identified by searching PubMed and the Cochrane Central Register of Controlled Trials. We included RCTs that compared short-course (up to 7 days) vs. long-course therapy (> or =2 days longer than short-course), with the same antimicrobial agent, in the same daily dosage, for patients with ABS. Twelve RCTs (10 double-blinded) involving adult patients with radiologically confirmed ABS were included. There was no difference in the comparison of short-course (3-7 days) with long-course treatment (6-10 days) regarding clinical success [12 RCTs, 4430 patients, fixed effect model (FEM), odds ratio (OR) 0.95, 95% confidence interval (CI) 0.81, 1.12]; microbiological efficacy; relapses; adverse events (10 RCTs, 4172 patients, random effects model, OR 0.88, 95% CI 0.71, 1.09); or withdrawals due to adverse events. In the sensitivity analysis comparing 5- vs. 10-day regimens, clinical success was similar, although adverse events were fewer with short-course treatment (5 RCTs, 2151 patients, FEM, OR 0.79, 95% CI 0.63, 0.98). Although antibiotics for acute sinusitis should be reserved for select patients with substantial probability of bacterial disease, accurate clinical diagnosis is often difficult to attain. Short-course antibiotic treatment had comparable effectiveness to a longer course of therapy for ABS. Shortened treatment, particularly for patients without severe disease and complicating factors, might lead to fewer adverse events, better patient compliance, lower rates of resistance development and fewer costs.

Figure 1

Flow diagram of the detailed process of selection of articles for our meta-analysis

Figure 2

Meta-analysis of clinical success at the test-of-cure assessment of per protocol patients treated with short-course vs. long-course antibiotic regimens. (Vertical line: ‘no difference’ line between compared treatments; horizontal lines: 95% confidence intervals; squares: point-estimates; size of the squares: weight of the study in the meta-analysis; diamond shape: pooled odds ratio plus 95% confidence interval)

Figure 3

Meta-analysis of microbiological efficacy against pretreatment isolated pathogens treated with short-course vs. long-course antibiotic regimens. (Vertical line: ‘no difference’ line between compared treatments; horizontal lines: 95% confidence intervals; squares: point-estimates; size of the squares: weight of the study in the meta-analysis; diamond shape: pooled odds ratio plus 95% confidence interval)

Figure 4

Meta-analysis of adverse events reported for patients treated with short-course vs. long-course antibiotic regimens. (Vertical line: ‘no difference’ line between compared treatments; horizontal lines: 95% confidence intervals; squares: point-estimates; size of the squares: weight of the study in the meta-analysis; diamond shape: pooled odds ratio plus 95% confidence interval)