Antibiotics Are Useless In Treating Most Sinus Infections

An anonymous reader writes "While doctors routinely prescribe antibiotics to treat sinus infections, researchers on Tuesday revealed that amoxicillin, the most commonly prescribed medication for nasal cavity inflammation and sinuses, was just as effective as a dummy pill. Researchers from the Washington University School of Medicine in St. Louis, Missouri, found that there was no significant difference in symptoms between patients taking amoxicillin to those who took the placebo three days after starting the pills were administered."

Comments

What does this sentence mean?

[fredrated]

"there was no significant difference in symptoms between patients taking amoxicillin to those who took the placebo three days after starting the pills were administered."

Re:What does this sentence mean?

[compro01]

Each group started on their pills and they checked for effect 3 days later.

Re:What does this sentence mean?

[troc]

Antibiotics are very quick - their major effect is in the first couple of days of a 10 day (2 week, whatever) course. The extra week or more of pills is to make absulutely sure that everything that can be killed off, is. This is to prevent (or at least restrict) the chance of any drug-resistant strains developing.

One of the major problems in countries like France (where drugs are handed out like sweets) and in the developing world (where people can't afford the whole course, or save some for "next time") is people not finishing up a full course of antibiotics because 3 days in, they feel well and can't see the need to swallow any more of the evil pills that have given them diarrhoea and other stomach problems (the main side effect of broad spectrum antibiotics....).

Re:What does this sentence mean?

[i.r.id10t]

Which is why you should eat active yogurt cultures when you are on antibiotics ...

Re:What does this sentence mean?

[CSMoran]

Humans are bad at understanding nested stuff, luckily for me, I'm a programmer.

You're definitely not a compiler -- you missed the syntax error at the end of the original sentence...

Re:What does this sentence mean?

[j00r0m4nc3r]

Sounds like a great plan, for the three people on the planet with no other responsibilities.

Re:What does this sentence mean?

[frenchbedroom]

Your first solution (coming over to the clinic each day) could theoretically work, but it's highly inconvenient in practice. There are still very sparsely populated areas in France, where commuting every day to the clinic is just not realistic. Not to mention the work overload on the clinics and hospitals, where nurses have more important stuff to worry about than checking if non-bedridden, able-bodied adults take their pills.

Your second solution is waaaaaay too easy to cheat out of, and it's also bad for the environment as it encourages people to throw their medication in the trash or in the sewers... when they should take it to the chemist's for safe disposal.

Personally I always take the full course when I'm on antibiotics, and when I have a friend or relative telling me they're on antibiotics, I remind them to complete the treatment.

The one thing I don't like about medication in France is that you almost always have to buy more than you need, because it comes in boxes of X pills, where X is never a multiple of the amount you need. That's actually one of the reasons why France is a drug champion, it skews the statistics. As I understand it, when you go to the chemist's in many other countries, they still do their traditional job of weighing the amount of drugs you need. Here in France they just push boxes.

Re:What does this sentence mean?

[geogob]

It depends which antibiotics. Some are very selective, others "wideband" so to speak. Many will have absolutely no effect on the intestinal microbiota. Others will completely kill it off, make the need of active yogourt to repolulate it.

(but INAMD... just what I understood through experience).

Re:What does this sentence mean?

[Americano]

Make them come over to the clinic for their daily dose.

And when they feel better three days in, instead of stopping the antibiotics at home, they'll just stop showing up at the clinic. Showing up at the clinic daily would, in fact, make it MORE difficult for people to do a full course. "I could've taken the antibiotics at home, but stopped because I felt fine," is ignorance that can be mostly eliminated with proper patient education by doctors and pharmacists - "It is VERY important that you take the entire round of antibiotics. Here's why, and you can read this alarming pamphlet with full color nasty photos of tuberculosis victims to underscore the point."

"I could've taken the antibiotics at the clinic but it's 30 minutes out of my way and a huge hassle and I felt fine," is a much bigger problem to work around.

And seriously - fining people for not finishing the course? Good luck creating a giant new invasive government infrastructure to monitor and collect the fines. And good luck penalizing the poor & uneducated who are predominantly the ones who don't finish the course - because "I felt fine, and the drugs are expensive, so why not save them for a time when I don't feel fine again?" or "because I felt fine, and I have no comprehension of how these things work or why it's important to take them, so why bother?" Do you really think that $500k/yr Senior VP at BofA is going to not bother taking his meds? Of course not. You think the kid who had to work 20 extra hours last week to afford the meds might? Sure.

Re:What does this sentence mean?

[Dunbal]

No. Results are usually seen within 24 hours and if there is no improvement after 48 hours the treatment can be considered ineffective. How do I know? I'm a doctor.

Re:What does this sentence mean?

[ryanov]

Oh awesome. I know that when I feel like shit, the first thing I want to do is drag myself out into the cold to get antibiotics EVERY DAMN DAY.

Re:What does this sentence mean?

[geekoid]

exactly

Re:What does this sentence mean?

[Dunbal]

Medicine.

What does work?

[svendsen]

Whiskey!

Re:What does work?

[fuzzyfuzzyfungus]

Assuming the labeling is following conventions for homeopathic dilution notation, I'm not surprised that that stuff would clear your sinuses good and hard, and not because of my boundless confidence in homeopathy...

A '3x' dilution is three successive 1:10 dilutions of the substance indicated in some neutral solvent. "Capsicum 3x" would be .1% capsaicin. Not exactly riot-cop stuff; but it'll definitely give you a bit of a kick. The unspecificed amount of Eucalyptol will likely get the sinuses cleared out as well...

There is, of course, nothing wrong with using plant-derived compounds that cure what ails you(that and sharp objects were, after all, basically the whole of medicine until the chemists really started to gear up in the late 19th and 20th century...); but the marketing as 'homeopathic' of drugs with concentrations well in the conventionally active range always annoys me.

Biofilms

[tmosley]

You can't effectively treat biofilms with antibiotics. And that is exactly what this type of infection is--a biofilm.

A better approach is the use of biofilm "release" enzymes that signal the cells within the biofilm to stop producing EPS and detach from whatever surface they are clinging to. Use of such enzymes alongside antibiotics in a medical setting is likely to work even better.

Re:Biofilms

[BlueParrot]

I'm by no means an expert in the field, but wouldn't that increase the risk of sepsis for some types of infections? I mean, the last thing you want is for the bacteria to start spreading throughout the circulatory system, and telling them to split up and release seems like it might do just that.

Re:Biofilms

[ackthpt]

You can't effectively treat biofilms with antibiotics. And that is exactly what this type of infection is--a biofilm.

A better approach is the use of biofilm "release" enzymes that signal the cells within the biofilm to stop producing EPS and detach from whatever surface they are clinging to. Use of such enzymes alongside antibiotics in a medical setting is likely to work even better.

I just eat spicy food (liberal use of capsicums.) My body reaction is to produce more sinus mucus. Seems to work, not enirely certain how, though perhaps someone more informed on what the increase does .. though it is worth noting most of these infections coincide with winter and thus drier air. Keeping sinus from drying or keeping the mucus in productions appears to limit spread and duration of infections (though could this be how the body is meant to work?)

Re:Biofilms

[tmosley]

Certainly. In addition to research performed by my own research group, the "Big Daddy" of biofilm research is Bill Costerton. His group puts out oodles of papers on the subject. This was merely the first that popped up in a Google Scholar search, though it is one that we have referenced for our own publications: http://www.sciencedirect.com/science/article/pii/S0140673601053211

Re:Biofilms

[tmosley]

That is why you combine the treatment with antibiotics. Planktonic bacteria are highly susceptible to all manner of natural and artificial defenses. If the area has the release enzyme in place, then they won't settle on a surface and start growing. The body can deal with individual bacteria in the bloodstream pretty easily. It's likely clots of biofilm that cause problems.

Re:Biofilms

[tmosley]

Sounds dumb, but it's actually highly effective. Unless the tissue itself is compromised (it always will be to some extent), the mucus production will float the infected mass away and confine it. It is also helpful to use a neti pot (clean water please), as that will wash away anything that is physically jammed in your upper sinuses. That is personal experience, not a course advised by systematic studies (my lab does only in vitro and animal work).

Re:Biofilms

[Pharmboy]

Take two dozen spicy wings, drink lots of fluids, and call me in the morning.

Yes, it does work well from my experiences. I eat a lot of spicy food anyway, but ramping it up with lots of water does seem to open up the head. Capsicums are irritants (tasty irritants) that make your sinuses want to float them out. As long as you drink plenty of water with them, your body will do the rest. Not sure about a major sinus infection, but it surely works great on the typically stuffy head syndrome that I get often enough in the winter.

slashdot title also written by a moron

[rubycodez]

amoxicillin, because there are no other antibiotics on planet earth.

yeah focus on symptoms, because progression of infection is irrelevant. three days, because all antibiotics cure by monday morning if course started friday morning

Re:slashdot title also written by a moron

[rwven]

My thought exactly. Clindamycin and Biaxin are especially good at treating sinus infections. Why they used a drug like amoxicillin is beyond me...

Re:slashdot title also written by a moron

[sjames]

No, amoxicillin because that is by far the most common prescription for sinus infections. It makes sense to see if that's actually helping, doesn't it? Now that we know it isn't, we know we need to consider either no prescription or a different one. We can then do studies to see how that works out.

Re:slashdot title also written by a moron

[skydyr]

Don't you know that all antibiotics are the same, work on the same infections in the same manner, and are only renamed for marketing purposes and in case some idiot thinks he has an allergy to one?

Re:slashdot title also written by a moron

[Kilrah_il]

If I may offer you a small advice, as an ENT doctor, use nasal irrigation. Many studies have showed that it is as important as antibiotics in the treatment of sinusitis.
Good luck!

Re:slashdot title also written by a moron

[Formalin]

Hmm, I don't know about that, as I've been prescribed Penicillin V within the last 5 years. You know, stuff from the dawn of antibiotics. (I've also had more modern antibiotics as well, so it's not a lack of them being available).

However, I live in a country that puts health before profits, so that could be related.

On the other hand, I suppose some of the early-gen antibiotics are being used less these days simply because in a lot of cases, they don't work very well. Doctor doesn't want you coming back in a week for something newer because the infection was penicillin resistant, or so. Which of course makes bacteria more exposed to new drugs, which makes them less effective... ad nauseam.

Here's a link to the actual study at JAMA's site

[stillnotelf]

http://jama.ama-assn.org/content/307/7/685.short I can't tell if it's paywalled or not - it appears to be. Pubmed hasn't indexed it yet (not that they offer free articles from JAMA anyway).

Obvious...

[Covalent]

Most sinus infections are viral. Nothing to see here.

Re:Obvious...

[stillnotelf]

From the paper: "All study participants met the recommended clinical criteria for acute rhinosinusitis[1] and are representative of patients for whom antibiotics might be prescribed." [1] is Hickner JM, Bartlett JG, Besser RE, Gonzales R, Hoffman JR, Sande MA, American Academy of Family Physicians; American College of Physicians-American Society of Internal Mediciine; Centers for Disease Control; Infectious Diseases Society of America. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Ann Intern Med. 2001;134(6):498–505.

Re:Obvious...

[level_headed_midwest]

You are both right. Most sinus infections are viral, and many patients with viral sinus infections demand that the doctor "do something," which generally means they want antibiotics. Many times they still demand antibiotics even though the doctor explains that antibiotics will not work for their *viral* infection. Thus anybody with sinusitis, be it viral or bacterial, is somebody who "might" be prescribed antibiotics.

Re:Lets make Antibiotics obsolete

[khb]

Unfortunately some people need them. My son hearing loss is ascribed to under treatment of sinus infections

Few doctors use an endoscope to examine and sample the nasal passages. So they prescribe blind. That is what's ineffective. When they can see and sample the pus diagnosis and choice of an antibiotic suitable for the specific pathogen is reliable.

Pity the paper didn't point out the effective course of treatment, focusing solely on the known (but common) ineffective approach.

Over-extapolating

[wonderboss]

Big leap from "no significant difference in symptoms between patients taking amoxicillin to those who took the placebo"
to "Antibiotics Are Useless In Treating Most Sinus Infections". How many bugs are resistant to amoxicillin at this point?
How many of the patients had bacterial infections?

inaccurate summary

[cinnamon colbert]

abstract is here http://jama.ama-assn.org/content/307/7/685.abstract
story itself, paid for probably with tax dollars is paywalled
The abstract says that yes, at 3 days, amoxicillin and placebo similar, but there was a diff at day 6
Also, total number of patients studied is quite small - Typical Bull**** "MD" science - mds just don't know how to do science, and they constantly flood the literature with these worthless studies, so the net result is a negative, cause you have towaste brain power to not pay attention

However, what is of more interest is the hard to read format of the abstract, which is a deliberate format imposed by the medical journals; the use of statistics in parenthesis, eg quote, mean difference between groups of 0.03 [95% CI, 0.12 to 0.19]) and on day 10 (mean difference between groups of 0.01 [95% CI, 0.13 to 0.15]), but differed at day 7 favoring amoxicillin (mean difference between groups of 0.19 [95% CI, 0.024 to 0.35]).
makes the abstract almost impossible to read; this practice has been criticized, but the idiot mds of course don't listen.
Not only that, with the number of people in the study, if you know naything of the history of medical studies, to give CIs is just BS, crazy statistics for no reason other then to tget a publication or satisfy the wierdness of hte editors; everything that is wrong with academic medicine is in this abstract
sorry for rant

Re:Here's a link to the actual study at JAMA's sit

[stillnotelf]

Here are some interesting points from the paper:

A) Someone's got a sense of humor: "The primary outcome was measured using the modified Sinonasal Outcome Test-16 (SNOT-16), a validated and responsive measure."

B) They did no testing whatsoever to ensure the sinus infections _were_ bacterial - but they apparently usually are, and are usually diagnosed as such symptomatically instead of by culture (in other words, they followed normal practices in deciding who to give antibiotics to).

C) They did no testing to see if resistant bacteria could be isolated from any patients.

Putting B and C together...clearly the medical community is overprescribing antibiotics, but there may be some question of whether it's resistant bacterial infections or poor diagnosis of bacterial vs. viral infections.

Nope

[geekoid]

THE AC submission was alarmist and wrong.

The research did not show the anitbiotics are useless.

It showed the Amoxicillin had no significant statistical difference at day three. BUT statistically significant results on day 7, no difference on day 10.

What this means is the people taking Amoxicillin got better sooner.

The person who wrote the headline and summary should be ashamed of themselves.

my favorite sinus remedy: simple, cheap

[nido]

Doctors have a tendency to recommend things that only they can recommend: prescription drugs, surgery, etc. They figure if you could do it yourself you'd have already done it.

But there's an ancient treatment for sinus problems that works really well: nasal irrigation. Basically, you add 1/2 tsp salt to a cup of water, and flush that through your nasal cavity.

Wall Street's media was overjoyed when someone with parasites in their water supply recently died after they used their neti pot. So boil your water first if that's a problem where you live, mkay? (This is covered on the link above...)

Re:my favorite sinus remedy: simple, cheap

[Andy Dodd]

This is how I beat well over half of the sinus infections I get - nasal irrigation works great.

However, sometimes the infection is stubborn and it resists 1-2 weeks of irrigation, staying in a steady state of no improvement. At that point I'll usually give in and start antibiotics, and with one exception (Normally my infections are triggered by normal colds initially, or allergies, in this case one of my peak allergy periods occurred two weeks AFTER the initial infection trigger, which was sewage-laden dust from the September 2011 Susquehanna flooding), they have always cleared up the infection in only a day or so.

I think the problem is that in the article given, the doctors in question are probably starting the antibiotics too early - if it's the first few days of "infection" it's very difficult to separate viral causes (just a cold), allergic causes, and actual bacterial causes. Now if you're at nearly 2 weeks of routine nasal irrigation and you have frequent bright yellow discharge restart 2-3 hours after you irrigate - at that point it's much more likely to be bacterial.

Re:my favorite sinus remedy: simple, cheap

[Anonymous Coward]

Except they don't really work for infections. By the time you're feeling symptoms of a sinus infection, it's already in your bloodstream, you can't just wash it away by pouring water up your nose. Now, it's not to say they're worthless, especially if you use them on a regular basis. The reason sinus infections are so common is that the mucus in your nose provides an ideal environment for bacteria to grow. Since a colony can grow in the mucus in peace (there are no white blood cells in snot), it can get quite strong before it enters the bloodstream, at which point it's too late for your body to easily and quickly fight off. Nasal irrigation can also help with recurrence, since it's possible for a bacterial colony to take hold in your nose, and essentially keep reintroducing itself back into the bloodstream as your body fights it off. What nasal irrigation can't do though is actually fight off an infection. The congestion and runny nose associated with a sinus infection are symptoms, not the infection itself, which is in your bloodstream, and requires either natural antibodies or antibiotics to cure.

Re:my favorite sinus remedy: simple, cheap

[God'sDuck]

Except that improperly-done nasal irrigation can kill. There were a couple people in Louisiana who used tap water to irrigate their sinuses, but the water was infected with an amoeba that killed them.

Ought to use distilled water for that at the least.

The instructions say to microwave the water to boiling, let it cool back to room temperature, then use it. I don't know of any cases of infection from people that followed those instructions.

that sucks

[james_van]

i currently a) have a sinus infection, b) am taking amoxicillin to treat it, and c) am completely miserable. hey science, thanks for making my day even worse!

I want a Placebo

[Oswald McWeany]

Can someone tell me where I can buy a pack of placebos please?

They seem to be really usefull in fighting off all sorts of diseases.

Re:I want a Placebo

[Hentes]

Just ask for homeopathic medicine.

Re:Lets make Antibiotics obsolete

[BlueParrot]

What we have hear is an ignorant mother fucker who has lived in a world with antibiotics and has no clue what life was like before them.

Which is exactly what you will get if antibiotics are over prescribed. Just look at what happened in countries that don't have effective regulations for medicines, like India. They're starting to see cases of tuberculosis that are resistant to ALL antibiotics, making it untreatable. When untreated TB kills 50% of patients.

Antibiotics are very useful, but they absolutely need to be used responsibly to minimise the risk of resistant infections. I'd argue abuse of antibiotics is even more troublesome than recreational drugs, since with antibiotic resistant infections the illnesses can then spread to other people, or even the whole world, causing severe damage that no narcotic could ever match.

Re:Obvious...Complications...

[BoRegardless]

It is entirely possible for a virus to give tissue damage that then results in a bacterial infection or visa versa!

Hence, I can easily believe that a rhinovirus could easily prevent clearing up a sinus infection with bacteria.

Biofilms, as mentioned by others, may also be an important variable.

It is anything but simple "Yes or No."

Mayo clinic: most are viral

[Bhrian]

A Mayo clinic study found 70% of sinus infections are viral instead of bacterial, so antibiotics actually make the infection worse. In addition, the antibiotics harm the rest of your immune system, leaving your worse off than before. My ENT introduced me to anti-viral nasal sprays for sinus infections. More of the drug reaches the infection and your GI system is left unharmed. The catch is they must be compounded at a pharmacy, need to be refrigerated, and are only good for 30 days. Many insurance companies cover them, but a lot of doctors don't know that option exists and just prescribe antibiotics.

Re:Lets make Antibiotics obsolete

[tmosley]

Antibiotics are fast going the way of the dodo. Phage is the future. Bacteriophages can be (and are) subjected to artificial evolution in small clinics to kill any strain of bacteria, no side effects, no long term resistance, no multibillion dollar research needed.

And that doesn't even mention new methods of drug design coming down the pike.

But you are exactly right, while those treatments are developed/gain acceptance in the West (phage therapy was originally developed in the nation of Georgia prior to the Soviet conquest), we must avoid antibiotic resistance. It should simply be noted that there are alternative technologies out there.

Re:Lets make Antibiotics obsolete

[Anonymous Coward]

We've known for years that Doctors have over prescribed Antibiotics for many ailments,

NO WE DO NOT KNOW THAT, please shut the fuck up and keep your popular culture non science views to your self, asshole.,

I guess the Harvard Medical School and the Harvard School of Public Health are now qualifying as non-science, huh
http://www.news.harvard.edu/gazette/2005/11.10/11-sore.html

Or how about this study, in which 44% of doctors "admitted sometimes prescribing antibiotics to patients who may not need them"
http://www.ncbi.nlm.nih.gov/pubmed/18196886

quacks

[v1]

I inherited bad sinuses from my mother who occasionally gets wicked sinus infections and has to go on hardcore antibiotics, the kind that WIPE your digestive tract and turn your poo white.

Fortunately for me genetics diluted the problem and I don't get one more than once a year usually. I've tried to tough it out, load up on decongestants and expectorants (due to drainage) etc and all that happens is it gets my throat torn up like hamburger from the infected runoff combined with coughing. Lucky me, I'm going through my yearly round of that right now actually. I started myself on decongestants immediately and have been pounding down pepsi almost nonstop to try to keep my sinuses and throat clear, but it still looks like the throat version of red-eye in there. I might actually beat it without antibiotics for the first time this time since I've jumped on it so aggressively.

In the past it's usually been the same story. Try to use over-the-counter meds for a week, finally it is getting so bad that the yellow mucus overnight has my throat destroyed by morning. (which will improve somewhat during the day, but not enough, it's a losing battle day to night) Enough of those and I can't stop coughing and I sprint into the local "convenient care" before work and a random doc looks at me and prescribes a decongestant and expectorant (that cost 2x the OTC usually) saying he doesn't want to give me antibiotics YET. Thanks.

So I'm back in the office 3-4 day later, almost unable to talk, haven't slept in days, throat killing me, and throat is totally red with green mucus streaking down in the back. "Ooooh! you have a bad sinus infection now! Here's some antibiotics!" Thanks. Now why couldn't we have just done this three days ago instead of putting me through two days of hell?

So the last two times I went in I relayed the above story and they conceded maybe antibiotics before it gets REALLY bad is a good plan for me. And I was sooo thankful, instead of it taking several more days of winding down misery, another two weeks in all, one round of refills to clear up, it was much better the very next day and cleared up in 5 days, both times.

Whoever says antibiotics don't help sinus infections is a quack. I seriously wonder what would happen to people like me if there were no antibiotics, could it get bad enough to hospitalize or kill me?

Re:quacks

[hillbilly1980]

Neti Pot. I used to have constant infections until I picked up one of these at the drug store. Boiled water that you let cool a bit and add on of it's little salt packets. Bing Bang Done! After 3 months of regular use I dialed down so i only do it once or twice a year when i have symptoms, but i went from constant throat and nose infections to the odd cough and sore throat a couple times a year.

Manuka honey!

[rak-wolf]

Thats kind of like saying exercise is dangerous because someone in Louisiana was run over while jogging down the middle of the interstate. Amoebas are dangerous even if you drink them.

My doc irrigates himself, and says it works best with Manuka honey.

Eat shit, not yogurt

[nbauman]

Your intestine has about a kilogram of symbiotic bacteria, with dozens of major species and hundreds of minor species. When you take antibiotics, you wipe out some or most of those species.

The bacteria in yogurt (usually a single species) are completely different. You can't repopulate the normal bacteria of your intestine with yogurt.

Nobody knows exactly how bacteria repopulate the bowel, but one thing you could try is a fecal transplant -- in other words, eat shit. This is not a standard medical procedure, but it's under serious investigation.

One of the problems with destroying the normal gut flora with antibiotics is that the gut is a major immunological organ. The immune system (all those white blood cells) has to decide whether a bacterial species is a normal symbiote or a pathogen, which is difficult and inaccurate. If you wipe out the normal flora and start again, your immune system might make mistakes.

Nobody knows what causes autoimmune diseases like multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosis, Crohn's, inflammatory bowel disease, etc., but wiping out the normal gut flora with antibiotics is a plausible mechanism.

So using antibiotics when you don't need them, in addition to promoting antibiotic resistance, might give you one of those horrible autoimmune diseases.

Re:Eat shit, not yogurt

[Dunbal]

A kilogram? Where did you get that number? Your intestine contains approximately 1 x 10^11 gram negative bacteria per ml, however I hardly think they make up a kilogram.

Re:Sinus infections don't last long enough?

[idontgno]

Last time I looked, my wife doesn't work in a class 5 hot facility (although sometimes the mud room around the cat litter box gets close), but the round of Cipro she had after a ruptured appendix saved her life.

And by "ruptured" I mean "completely detached and misdiagnosed for 24 hours" ruptured. I think her native stubbornness and strong immune system (the catbox again) kept her alive until the medicos figured out that that gall bladder shadow in her x-ray was actually her escaped appendix, especially since it was in her medical records that she'd had the damn gall bladder removed a year earlier at that very hospital.