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Medical Forum / Diseases and Disorders / Sinusitis / March 2007Another Study Shows Antibiotics Overprescribed For Sinusitis
Antibiotics overprescribed for sinus ills, study finds CHICAGO, Illinois (Reuters) -- U.S. doctors may be over-prescribing antibiotics for sinus infections, which are often caused by viruses and not bacteria, according to a study released on Monday. A review of two national surveys of visits to doctors and recommended treatments found antibiotics prescribed for about 82 percent of acute sinus infections and nearly 70 percent of chronic sinus infections, researchers at the University of Nebraska Medical Center in Omaha said. That "far outweighs the predicted incidence of bacterial causes. The literature repeatedly shows that viruses are by far the most frequent cause of acute rhinosinusitis," the study, published in this week's Archives of Otolaryngology-Head & Neck Surgery, said. The infections are considered acute when symptoms persist up to a month. They become chronic when they last for three months or more. Overuse of antibiotics, which are useless against viruses, is causing the evolution of drug-resistant bacteria that must be treated with the most expensive new antibiotics. http://www.cnn.com/2007/HEALTH/conditions/03/19/sinus.drugs.reut/ [ The recommendation is to only prescribe antibiotics when the infection has lasted a month or more. The problem, of course, is that in today's fast-paced economy, nobody can afford to stay sick for a whole month before getting the antibiotic! Therefore, the recommendation should have also emphasized all the many ways to relieve symptoms until the antibiotic is prescribed, especially irrigation. ]  SignatureSteven D. Litvintchouk Email: sdlitvin@earthlinkNOSPAM.net Remove the NOSPAM before replying to me. Gigantic hubrus on display but practically no rigor. This study is based upon compareing prescription patterns to a baseline frequency of sinusitis due to bacterial infection. However the criteria and test methods used to establish the baseline do not detect bacteria in biofilms, nor unculturable bacteria. If they are going to rule out bacteria and fungi it might be useful to use the tests that can actually reliably detect their presence. If the baseline is garbage the study is irresponsible garbage, because a biofilm can be averted or cut short when it is young, but it becomes more resistant to antibotics with every species it collects. Did they look at how many of the untreated cases developed into symptomic chronic sinusitis vs the antibotic treated cases? You bet they didn't. And they just approved a new cephalosporin for use in agriculture, that will promote resistance. Meta-analysis studies are really suspect; it's true--garbage in, garbage out. I do not believe that antibiotics are being grossly over prescribed any longer: just based on my own clinical experience. The message has been heard by patients and doctors, not to overtreat viral illness. If a patient has to suffer for a month to justify antibiotics, then we will start to see what I've seen this year: mastoiditis with bacterial meningitis, osteomyelitis. You can not take a a study like this and apply it globally to all patients. After 5 surgeries, when I get a sinus infection, it comes on quickly and becomes severe. If I waited a month, I'd be in the hospital. Let's be honest about where the antibiotic resistance is primarily coming from: overuse in livestock and agriculture use. Quit beating up the patients and withholding medications. Organizations, like certain HMO's, will use studies like this to create clinical guidelines, and that will do a huge disservice to patients. Judy > Gigantic hubrus on display but practically no rigor. > [quoted text clipped - 12 lines] > symptomic chronic sinusitis vs the antibotic treated cases? > You bet they didn't. > You can not take a a study like this and apply it globally to all > patients. Thank you. Can we make that into bumper stickers and t-shirts? 1) On the dry eye forum, I tried to explain 'sample size' to the uninitiated. 34.3 million chronic sinusitis sufferers -- all causes (worthless, but ... for example) [1]. If you have a "truly randomized" sample and you want a clinical trial that results in: - confidence interval of 2% - confidence level of 99% Then you would have to have 4,160 chronic sinusitis sufferers in your clinical trial. Yeah. Good luck with that. Even then ... biology doesn't really reduce to statistics all that agreeably ... darned biology. 2) We don't slice and dice data subsets to understand: - who got better, and why? - who didn't get better, and why? - who got worse, and why? - who had which nasty "adverse events," and why? I won't bother with my "it's all about money" explanation -- you know: that reducing the potential universe of customers BY narrowly targeting drugs FOR maximum safety and efficacy, by USING this sort of approach, diminishes BigPharma's ROI. No. I won't bother. As for me ... tempted as I've been ... if I'm getting sick, I won't go a month without seeking drugs. As I say, I've "beaten an infection" maybe twice, and--odds are--I didn't beat them at all. I just drove them deeper underground :-( [1] http://www.wrongdiagnosis.com/c/chronic_sinusitis/prevalence.htm > Let's be honest about where the antibiotic resistance is primarily > coming from: overuse in livestock and agriculture use. No, Judy, a large part of it came from the overuse of antibiotics to treat viral infections in human patients. Back in the 1950's especially, patients used to run to the doctor for a penicillin shot at the first sign of illness. All too often the illness turned out to be viral, or something self-limiting like skin abscesses. Result: 90% of staph bacteria are now resistant to penicillin. For those who are allergic to penicillin, erythromycin was overprescribed. Half of staph are now resistant to erythromycin too. As for sinusitis: Obviously if you already have a history of chronic sinusitis (you and I have had multiple surgeries already), then the next time you get acute sinusitis, it is likely to be infectious. But that's not where the problem is coming from. It's coming from patients who run to the doctor for an antibiotic for any sign of upper respiratory trouble--"just in case" it's bacterial. For ordinary viral infections, the inflammation and blockages of the sinuses should diminish after your immune system fights off the virus. If it does not, which can predispose you to more sinus infections, the cause of that needs to be investigated. Whether it's anatomical, allergy, air pollution, whatever. Antibiotics are being prescribed in lieu of this type of wellness program. They are a short-term quick fix while the underlying sinus disease will continue to worsen silently snd insidiously--till chronic sinusitis occurs anyway. Which was my personal experience too. >> Did they look at how many of the untreated cases developed into >> symptomic chronic sinusitis vs the antibotic treated cases? A few weeks of antibiotics to treat an acute sinus infection won't prevent chronic sinusitis. In fact, for most chronic sinusitis patients, like myself, it's the REVERSE: They have already had multiple bouts of acute sinusitis, each treated with antibiotics. Till one day the antibiotics just seem to stop working and then the sinusitis becomes chronic. Tens of millions of Americans now suffer from chronic sinusitis; it's become a virtual epidemic. The overprescription of antibiotics has *NOT* prevented this epidemic. In fact, it may be causing it. And that's because the underlying sinus disease has progressed despite all the antibiotic treatment. Once the antibiotic seems to have cured your sinus infection, it's easy to just say "Well, I'm all right now" and not think about why you keep getting sinus infections. But unlike the common cold, you shouldn't be getting multiple sinus infections unless there's something wrong somewhere that needs to be diagnosed and corrected. SignatureSteven D. Litvintchouk Email: sdlitvin@earthlinkNOSPAM.net Remove the NOSPAM before replying to me. Stephen: Where do you get your stastics? Any references? > Result: 90% of staph bacteria are now resistant to penicillin. For > those who are allergic to penicillin, erythromycin was overprescribed. > Half of staph are now resistant to erythromycin too. The only thing the staph in my nose is resistant to is tetracycline. If it was there as a monoculture I would have no problem. Biofilm, look it up. On 3/21/07 11:04 AM, in article useMh.129828$_73.101353@newsread2.news.pas.earthlink.net, "Steven L." <sdlitvin@earthlinkNOSPAM.net> wrote: >> Let's be honest about where the antibiotic resistance is primarily >> coming from: overuse in livestock and agriculture use. [quoted text clipped - 49 lines] > unless there's something wrong somewhere that needs to be diagnosed and > corrected. Couple of points As a rule the antibiotics do kill the bacteria. You still need the body's natural immune system - good white cells etc. The common reason the infections return is that the cilia have not returned to normal activity. In my 5 person ENT group we routinely see persons who have "failed" three antibiotic courses and all we do is work on restoring cilia function. Remember the "ooooommmmm" The resistant bacteria, in a large measure came from failure to complete the full course of antibiotic. Routinely patients tell me they still have 1/2 bottle of an antibiotic left from months ago that they stopped when they felt better. Stopping the antibiotic in mid course is the best way to grow resistant organisms. It helps if your doctor belongs to the "drug of the week". The hospitals routinely publish which bugs are sensitive and which are resistant to specific antibiotics in your area and this is very useful information for your doctor to use in prescribing. These vary from area to area. > The resistant bacteria, in a large measure came from failure to complete the > full course of antibiotic. 80% of the antibiotics manufactured in the U.S. are dumped into feedlots and sprayed onto produce, and clearly has an effect on resistance, since all the organisms we're carrying are exposed to small doses at every meal (if we don't shop very carefully). What people take or don't take is a mere drop in the bucket. Susan On 3/22/07 2:11 PM, in article 56g9n8F28et5gU1@mid.individual.net, "Susan" <nevermind@nomail.com> wrote: > x-no-archive: yes > [quoted text clipped - 9 lines] > > Susan Not so. We regularly see patients who took an inadequate course of medication - stopped it when they felt better, restarted when they felt sick again and again took an inadequate dose - and now they have a resistant bug. This scenario has been followed and reported repeatedly and can be replicated in laboratory. > On 3/22/07 2:11 PM, in article 56g9n8F28et5gU1@mid.individual.net, "Susan" > <nevermind@nomail.com> wrote: [quoted text clipped - 14 lines] > medication - stopped it when they felt better, restarted when they felt sick > again and again took an inadequate dose - and now they have a resistant bug. The dose *might* have been sufficient if irrigation and other methods had been used to restore adequate drainage. If you can wipe out the infection quickly you can prevent the onset of antibiotic resistance. But that can be done by EITHER a much heftier and longer dose of antibiotic, or a shorter dose with an aggressive treatment program to open the blocked sinuses. Even prednisolone can be of assistance to shrink the swelling and unblock those ostia. SignatureSteven D. Litvintchouk Email: sdlitvin@earthlinkNOSPAM.net Remove the NOSPAM before replying to me. > Not so. We regularly see patients who took an inadequate course of > medication - stopped it when they felt better, restarted when they felt sick > again and again took an inadequate dose - and now they have a resistant bug. > This scenario has been followed and reported repeatedly and can be > replicated in laboratory. I'm not disuputing that this happens or that it's a problem. What I'm disputing is your dismissal of the role played by lifetime exposure to low levels of our most powerful antibiotics via food sources. Susan On 3/23/07 6:44 AM, in article 56i3suF28oa6uU1@mid.individual.net, "Susan" <nevermind@nomail.com> wrote: > x-no-archive: yes > [quoted text clipped - 9 lines] > > Susan Where do I say I am dismissing this? Which line or letter says I am dismissing it? If you must bark, show what you are barking at. The scenario I gave is one that any scientist can produce in any laboratory anywhere. And this si what we see in patients. Your reply to Susan's observation of the overuse of antibiotics in agriculture: which has been shown to create resistant salmonella: "Not so" Antibiotic resistance is multifactoral, and doesn't simply arise from patients who don't complete a "full" course of antibiotics. You see resistant organisms in patients and attribute it soley to noncompliance : I see widespread MRSA in the community, among patients who haven't taken antibiotics for years, and believe that the there are many factors that contribute to antibiotic resistance. Also, I see that the main approach to curbing antibiotic resistance is to attempt to prove that antibiotics should be not just used judiciously, but withheld in most cases. I believe in judicious prescribing, but blanket recommendations of not treating sinus infections for 30 days in all cases strikes me as potentially dangerous. That is what I am "barking at". Judy > On 3/23/07 6:44 AM, in article 56i3suF28oa6...@mid.individual.net, "Susan" > [quoted text clipped - 17 lines] > I gave is one that any scientist can produce in any laboratory anywhere. And > this si what we see in patients. On 3/24/07 10:57 AM, in article 1174759061.894473.243750@l77g2000hsb.googlegroups.com, "judy.n" > Your reply to Susan's observation of the overuse of antibiotics in > agriculture: which has been shown to create resistant salmonella: [quoted text clipped - 42 lines] >> I gave is one that any scientist can produce in any laboratory anywhere. And >> this si what we see in patients. As I say in my letter re "joining" ZAAP Zaap Antibiotic Abuse Personally Your neighbor may be the one who discontinues her antibiotic to let the bacteria develop a resistance. Or the guy who coughed in the elevator or on the airplane. So, all persons should be aware of this problem and should teach it to whomever they can. No doubt you are going to find cases where the antibiotic was with held and there were serious consequences. Its the same as not taking a chest X ray on everyone or an MRI on everyone. There are value judgments and regrettably the wrong decision can be made. What I propose is giving the patient methods that can assist in clearing the infection as an aid to reducing the need for the antibiotic. I suppose that' s why my book is not in a second edition. Unfortunately, your theory of that all resistance comes from not completing a prescribed course of antibiotics doesn't explain widespread resistance: How do you explain the fact that most cases of abscess in the community are now MRSA? How do you explain that when I had a pseudomonas osteomyelitis, I was working in a hospital, and the organism was resistant to most antibiotics, including cephalosporins: yet I'm allergic to cephalosporins and hadn't taken any for several decades? Antibiotic resistance is due to many reasons: overuse in non-bacterial infections, widespread use in agriculture, the ability of bacteria mutate and exchange genes that confer resistance. I'm sure undertreatment has some contribution to the problem, but it's not the only explanation. Judy > On 3/22/07 2:11 PM, in article 56g9n8F28et5...@mid.individual.net, "Susan" > [quoted text clipped - 18 lines] > This scenario has been followed and reported repeatedly and can be > replicated in laboratory. > x-no-archive: yes > [quoted text clipped - 6 lines] > all the organisms we're carrying are exposed to small doses at every > meal (if we don't shop very carefully). Let me repeat: If you're getting multiple sinus infections, you must find the underlying *cause*. Because a blocked sinus will not heal for good, no matter how many tons of antibiotics you pour in there, unless adequate drainage is restored. That is true for other types of infections too, from abscessed teeth to skin abscesses. Drainage of the pus or infectious material is *more* important than antibiotics. Without drainage, the bugs don't leave and those that survive the attacking antibiotics pass on their resistance to their progeny. So taking antibiotics for a blocked sinus or an abscessed tooth or a skin abscess without ensuring drainage is just promoting antibiotic resistance. For too many patients, antibiotics are the *only* treatment they ever get for their sinus infections. That won't cure them and it will promote antibiotic resistance. SignatureSteven D. Litvintchouk Email: sdlitvin@earthlinkNOSPAM.net Remove the NOSPAM before replying to me. And what if the underlying cause is a primary immunodeficiency? IgA and IgG subclass deficiencies are rampant: up to 1 in 300 people. No amount of surgery will help people with primary immunodeficiencies not get repeated bacterial respiratory infections. You are over simplying things here. Many patients with "normal" CT's will get recurrent infections, or some who have had severe infections will get such scarring and change in the lining of the sinuses from ciliated epithelium to squamous epithelium and be permanently predisposed to recurrent infection. Just like this article over simplified and declared that no one should receive treatment for the first 30 days of sinusitis infections--a one size fits all proclamation that is ridiculous, so is your declaration that if you open the blockage, you will cure sinus infections. A prominent surgeon at Harvard told a colleague of mine, ironically an allergist who had recurrent infections despite FESS, that "He could open the door, but he couldn't change the wallpaper." We need guidelines, and scientific observations, but over generalization helps no one. Prior guidelines from the Society of Otolaryngology gave a number of symptoms that needed to be present to diagnosis sinusitis and indicate a need for treatment. One of them was severe symptoms: there's no time frame associated with that. Severe symptoms should be treated: to make someone with severe pain, facial swelling, fever, etc, wait for 30 days is to ask for a brain abscess. One of my medical assistants brought her daughter in with high fever, periorbital swelling, prominence of the eyes--after a few days of a viral illness: she had frontal cellulitis with spread to the orbits and meninges. Should we have waited to treat her? Judy > > x-no-archive: yes > [quoted text clipped - 28 lines] > Email: sdlit...@earthlinkNOSPAM.net > Remove the NOSPAM before replying to me. Thanks for this JUDY ! --I had a fever from Sept 6 until late Feb and Not sure the prob is solved yet . I will be looking up Mastoiditis -and bacterial menengitis--I have a chronic year long sinus problems -many allergies -with no real explination for the long term fever We need a vaccine. There is now a vaccine for Streptococcus pneumoniae, if we had one for staph, e. coli and took the human pap shot, then I think that sinus infections would be much more rare. And I am ALL for removeing the pus, the mucus, the film. That IS the collection of critters, their protective polysacrides and amyloid protein, and the various white blood cells and the carcasses of same that have thrown their contents on the enemy. Washing this stuff out is important. But spraying saline on it is like trying to strip varnish with salt water. Not very effective. Vitamin C, EDTA, MSM, potassium nitrites, all make a much more effective wash. But not even the vulnerable bacteria are being killed in humans. And YES one should finish the antibotics. Human cells respond to things sticking to them by bringing them inside the cell membrane and sending what ever it was for digestion, but pathogenic bacteria like e coli exploit this route to get into the cytoplasm of surface cells where they can hide out from antibotics, so one has to take antibotics for long enough for the infected cells to slough off. It does not mean that the bacteria was antibotic resistant if it had been where it was exposed to it. And bacteria that can easily be killed by antibotic are resistant once they join a biofilm. http://www.biology.neu.edu/faculty03/lewis03.html Vaccine would definately be the perfered way to go, but if the viral/ bacterial basis of the disease is not recognised, then the vaccine will never happen. On 3/24/07 9:18 PM, in article 1174796311.289531.62930@p15g2000hsd.googlegroups.com, "truehawk" > Washing this stuff out is important. But spraying saline on it is like > trying to strip varnish with salt water. > Not very effective. Moistening the nose with saline is very helpful by thinning the thick mucus coat and allowing better movement of nasal cilia. Also helps avoid nosebleeds that accompany high altitude and dry weather. In winter the air is dry so saline is helpful. On Mar 24, 8:29 pm, TNARTL...@webtv.net (\( TN Artist, trish,tn \)) wrote: > Thanks for this JUDY ! --I had a fever from Sept 6 until late Feb and > Not sure the prob is solved yet . I will be looking up Mastoiditis -and > bacterial menengitis--I have a chronic year long sinus problems -many > allergies -with no real explination for the long term fever One thing: bacterial meningitis is an acute illness: you are horribly sick with fever, stiff neck, mental status changes. Mastoiditis on the other hand, can be a chronic infection in the mastoid area behind your head, and can linger. A chronic fever needs to be thoroughly evaluated. A bone infection is always a possibility--and chronic sinus infections can get into the bone. I really hope you have a physician who is evaluating you for the fever, it's a serious symptom. I hope you get to the bottom of this. Judy > Gigantic hubrus on display but practically no rigor. > [quoted text clipped - 12 lines] > symptomic chronic sinusitis vs the antibotic treated cases? > You bet they didn't. Since when is acute sinusitis symptoms for a month, and chronic = symptoms for 3 months. Who created that definition? Of course viruses cause sinus congestion and abnormal CT scans: in the first week of the illness: sinusitis is a clinical diagnosis, and the previous algorhytims used patient symptoms to determine the need to treat: fever, facial pain, fatigue, severe symptoms. Judy > > Gigantic hubrus on display but practically no rigor. > [quoted text clipped - 12 lines] > > symptomic chronic sinusitis vs the antibotic treated cases? > > You bet they didn't. Hearing Loss In Children Leads To Substantial Meningitis Risk http://www.sciencedaily.com/releases/2007/03/070320121206.htm And they also recomended that ear infections not be treated with antibotics! Such kidders! > Since when is acute sinusitis symptoms for a month, and chronic = > symptoms for 3 months. [quoted text clipped - 7 lines] >we will start to see what I've seen this year: mastoiditis with >bacterial meningitis, osteomyelitis. yeah and the kids that don't get antibotics for ear infections are at greater risk for meningitis. http://www.sciencedaily.com/releases/2007/03/070320121206.htm Hearing Loss In Children Leads To Substantial Meningitis Risk Science Daily - Children who are stricken with severe hearing loss are five times more likely to contract meningitis, according to a new study. -------------------------------------------------------------------------------- The study, conducted over a nine year period, monitored 663,963 children born in Denmark between 1995 and 2004. It identified 39 children with both hearing loss and meningitis; of these children, five were first diagnosed with hearing loss, and later, meningitis. Statistically, the authors determined the likelihood of a child developing meningitis after losing their hearing is five times that of other children; their research indicates that factor could in fact be as high as 12 times that of other children. The study's authors say their research provides evidence of an association of hearing loss and the onset of meningitis, providing physicians and parents with ample reason to be mindful of possible signs and symptoms of meningitis, and allowing for vaccination to be considered as a preventive step. Previous research by the Centers for Disease Control and Prevention determined that children who receive cochlear implants to counter hearing loss are more likely to develop meningitis. Worldwide, 90 of the 60,000 people receiving cochlear implant have been stricken with meningitis, drawing particular concern within the medical community. Reference: Otolaryngology- Head and Neck Surgery is the official scientific journal of the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF). The authors of the study are Erik Thorlund Parner, PhD, MSc; Jennita Reefhuis, PhD; Diana Schendel, PhD; Janus L. Thomsen, PhD; Therese Ovensen, PhD; and Poul Thorsen, PhD. Parner, Thomsen, and Thorsen are associated with the University of Aarhus, Denmark's Institute of Public Health. Schendel is associated with Centers for Disease Control and Prevention in Atlanta, GA. Ovesen is part of the ENT Department at Aarhus University Hospital in Denmark |
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