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Evidence-Based Medicine

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Using a simple set of clinical criteria is a cost-effective approach to treating suspected acute bacterial sinusitis

About 3 million people visit the doctor each year for symptoms that suggest sinusitis, but not all of these patients have a bacterial infection or need a prescription for an antibiotic. Strategies for diagnosing and treating suspected acute bacterial sinusitis can include no antibiotic treatment, empirical antibiotic treatment, clinical criteria-guided treatment, and x-ray guided treatment.

Joseph Lau, M.D., and colleagues at the Evidence-based Practice Center at New England Medical Center created a model to examine which of these approaches is a cost-effective strategy in most clinical settings for treating suspected acute bacterial sinusitis. The model simulated a 14-day course of illness, included sinusitis prevalence, antibiotic side effects, serious sinusitis complications, costs, and symptom severity. The researchers concluded that in most primary care settings, the evidence supports using clinical criteria to guide antibiotic treatment of otherwise healthy patients with mild to moderate symptoms suspicious for community-acquired acute bacterial sinusitis.

Use of antibiotics based on symptoms alone may be cost effective if the goal is to minimize symptom days, if prevalence of mild and moderate symptoms exceeds 63 percent, and if patients have severe symptoms and prevalence exceeds 51 percent. However, basing treatment on symptoms alone would mean that many patients would receive antibiotics unnecessarily. If this resulted in increased antibiotic resistance, costs would substantially rise, but benefits would decrease both for using clinical criteria to determine treatment and for treating patients empirically with antibiotics. The researchers found that basing initial antibiotic treatment on costly radiography tests is never cost effective.

This study was based on a systematic review of the literature by New England Medical Center's Evidence-based Practice Center (EPC) and was supported by the Agency for Healthcare Research and Quality (contract 290-97-0019, HS09796, and National Research Service Award training grant T32 HS00060). The EPC produced two evidence reports and summaries based on their review (see Editor's Note).

This study is reported in "Strategies for diagnosing and treating suspected acute bacterial sinusitis," by Ethan M. Balk, M.D., M.P.H., Deborah R. Zucker, M.D., Ph.D., Eric A. Engels, M.D., M.P.H., and others, in the October 2001 Journal of General Internal Medicine 16, pp. 701-711.

Editor's Note: Copies of the full evidence report from which this study was drawn, Diagnosis and Treatment of Acute Bacterial Sinusitis (AHRQ Publication No. 99-E016), are available from the AHRQ Publications Clearinghouse and a summary of the report (AHRQ Publication No. 99-E015) is also available from the AHRQ Publications Clearinghouse.

A supplement, Diagnosis and Treatment of Uncomplicated Acute Sinusitis in Children (AHRQ Publication No. 01-E005), is available from the AHRQ Publications Clearinghouse and a summary of the supplement (AHRQ Publication No. 01-E007)is also available from the AHRQ Publications Clearinghouse.

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