- Email: [email protected]
Antibiotics for acute rhinosinusitis
Correspondence
We declare that we have no conflict of interest.
Alexander Bjarnason, Samuel N Adler, *Ingvar Bjarnason [email protected] Department of Anthropology, University College London, Gower Street, London, UK (AB); Department of Gastroenterology, Bikur Cholim Hospital, Rechov Straus 5, Jerusalem, Israel (SNA); and Department of Gastroenterology, King’s College Hospital, London SE5 9RS, UK (IB) 1
2
3
4
5
Besselink MGH, van Santvoort HC, Buskens E, et al, for the Dutch Acute Pancreatitis Study Group. Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. Lancet 2008; 371: 651–59. Bjarnason I, Takeuchi K, Bjarnason A, Adler SN, Teahon K. The G.U.T. of gut. Scand J Gastroenterol 2004; 39: 807–15. Bjarnason I, Hayllar J, Macpherson AJ, Russell AS. Side effects of nonsteroidal antiinflammatory drugs on the small and large intestine. Gastroenterology 1993; 104: 1832–47. Bjarnason I, Hayllar J, Smethurst P, Price AB, Menzies IS, Gumpel MJ. Metronidazole reduces inflammation and blood loss in NSAID enteropathy. Gut 1992; 33: 1204–08. Ammori BJ. Role of the gut in the course of severe acute pancreatitis. Pancreas 2003; 26: 122–29.
that benefit more than others from antibiotic treatment. But the message is the same as it has been for years: acute sinusitis based on clinical symptoms will not be cured with antibiotics. I am afraid that these findings will not stop us from prescribing antibiotics. We still believe that a subgroup that benefits exists. This idea is not an illusion. Lindbaek and colleagues2 showed that antibiotics were of great benefit in patients in primary care with acute sinusitis diagnosed by CT scanning (number needed to treat 3). However, the large effect seen for that study could at least partly have been attributable to chance. It was the only study in primary care with CT scanning as a selection criterion and replication of the findings would be useful. A further criticism might be that CT scanning is not a diagnostic tool in primary care. More diagnostic research in primary care should be done first. Up until now there have been no studies with large numbers on diagnosis of sinusitis with CT scanning, sinus puncture, and clinical signs and symptoms.3 But the possibility that we might need CT scanning to identify a subgroup should be accepted. Doctors are more at ease knowing who to treat and who not, as was shown with an identical meta-analysis on acute otitis media.4 I declare that I have no conflict of interest.
R A M J Damoiseaux [email protected] General Practice of Hof van Blom, Hof van Blom 7, 8051 JT Hattem, Netherlands
Antibiotics for acute rhinosinusitis
1
The results of the meta-analysis by Jim Young and colleagues (March 15, p 908)1 are robust, but, for clinicians, a bit disappointing. The hope was that this effort would provide us fieldworkers with a set of subgroups
2
www.thelancet.com Vol 372 July 12, 2008
3
Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet 2008; 371: 908–14. Lindbaek M, Hjortdahl P, Johnsen UL. Randomised, double blind, placebo controlled trial of penicillin V and amoxicillin in treatment of acute sinus infections in adults. BMJ 1996; 313: 325–29. Engels EA, Terrin N, Barza M, Lau J. Meta-analysis for diagnostic tests for acute sinusitis. J Clin Epidemiol 2000; 53: 852–62.
4
Rovers MM, Glasziou P, Appelman CL, et al. Antibiotics for acute otitis media: a metaanalysis with individual patient data. Lancet 2006; 368: 1429–35.
We welcome Jim Young and colleagues’ meta-analysis of individual patient data from studies investigating the value of antibiotics for acute rhinosinusitis.1 Combining the data from studies with similar patients, interventions, and outcomes can provide more precise estimates and thus resolve discussions with respect to contradicting outcomes of individual studies. Comparing the overall results for the odds ratio calculated in their “classic” meta-analysis with the individual patient data meta-analysis shows highly similar point estimates and CIs (1·35, 95% CI 1·15–1·59, and 1·37, 1·13–1·66, respectively), both significant. However, the number needed to treat (NNT) calculated from the individual patient data turns out to include the point of no effect, and thus is not significant. To our surprise, Young and colleagues do not address this discrepancy between the significant odds ratio and the non-significant NNT. For no apparent reason, they chose to give preference to the latter result in their Discussion. Moreover, the Summary only provides the NNT and ignores the odds ratio. For reasons of transparacy, we suggest that Young and colleagues provide their arguments for making the choice they did. Ideally, this choice should have been made in their research protocol.
Science Photo Library
many misused alcohol, were critically ill, and infected. All of these conditions are characterised by increased intestinal permeability and the effect is additive.5 Exposing an extremely leaky intestine to an additional bacterial load, albeit in apparently “friendly” probiotic form, seems to have led to severe intestinal damage. All intestinal bacteria have the potential to cause disease if they are in the wrong place. Probiotics should only be contemplated if the integrity of the gastrointestinal tract is not severely compromised: there are no “good” intestinal bacteria, only less harmful ones.
We declare that we have no conflict of interest.
*Johannes C van der Wouden, Sten P Willemsen [email protected] Department of General Practice, Erasmus Medical Center/University Medical Center, PO Box 2040, 3000 DR Rotterdam, Netherlands 1
Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a metaanalysis of individual patient data. Lancet 2008; 371: 908–14.
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We declare that we have no conflict of interest.
Alexander Bjarnason, Samuel N Adler, *Ingvar Bjarnason [email protected] Department of Anthropology, University College London, Gower Street, London, UK (AB); Department of Gastroenterology, Bikur Cholim Hospital, Rechov Straus 5, Jerusalem, Israel (SNA); and Department of Gastroenterology, King’s College Hospital, London SE5 9RS, UK (IB) 1
2
3
4
5
Besselink MGH, van Santvoort HC, Buskens E, et al, for the Dutch Acute Pancreatitis Study Group. Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. Lancet 2008; 371: 651–59. Bjarnason I, Takeuchi K, Bjarnason A, Adler SN, Teahon K. The G.U.T. of gut. Scand J Gastroenterol 2004; 39: 807–15. Bjarnason I, Hayllar J, Macpherson AJ, Russell AS. Side effects of nonsteroidal antiinflammatory drugs on the small and large intestine. Gastroenterology 1993; 104: 1832–47. Bjarnason I, Hayllar J, Smethurst P, Price AB, Menzies IS, Gumpel MJ. Metronidazole reduces inflammation and blood loss in NSAID enteropathy. Gut 1992; 33: 1204–08. Ammori BJ. Role of the gut in the course of severe acute pancreatitis. Pancreas 2003; 26: 122–29.
that benefit more than others from antibiotic treatment. But the message is the same as it has been for years: acute sinusitis based on clinical symptoms will not be cured with antibiotics. I am afraid that these findings will not stop us from prescribing antibiotics. We still believe that a subgroup that benefits exists. This idea is not an illusion. Lindbaek and colleagues2 showed that antibiotics were of great benefit in patients in primary care with acute sinusitis diagnosed by CT scanning (number needed to treat 3). However, the large effect seen for that study could at least partly have been attributable to chance. It was the only study in primary care with CT scanning as a selection criterion and replication of the findings would be useful. A further criticism might be that CT scanning is not a diagnostic tool in primary care. More diagnostic research in primary care should be done first. Up until now there have been no studies with large numbers on diagnosis of sinusitis with CT scanning, sinus puncture, and clinical signs and symptoms.3 But the possibility that we might need CT scanning to identify a subgroup should be accepted. Doctors are more at ease knowing who to treat and who not, as was shown with an identical meta-analysis on acute otitis media.4 I declare that I have no conflict of interest.
R A M J Damoiseaux [email protected] General Practice of Hof van Blom, Hof van Blom 7, 8051 JT Hattem, Netherlands
Antibiotics for acute rhinosinusitis
1
The results of the meta-analysis by Jim Young and colleagues (March 15, p 908)1 are robust, but, for clinicians, a bit disappointing. The hope was that this effort would provide us fieldworkers with a set of subgroups
2
www.thelancet.com Vol 372 July 12, 2008
3
Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet 2008; 371: 908–14. Lindbaek M, Hjortdahl P, Johnsen UL. Randomised, double blind, placebo controlled trial of penicillin V and amoxicillin in treatment of acute sinus infections in adults. BMJ 1996; 313: 325–29. Engels EA, Terrin N, Barza M, Lau J. Meta-analysis for diagnostic tests for acute sinusitis. J Clin Epidemiol 2000; 53: 852–62.
4
Rovers MM, Glasziou P, Appelman CL, et al. Antibiotics for acute otitis media: a metaanalysis with individual patient data. Lancet 2006; 368: 1429–35.
We welcome Jim Young and colleagues’ meta-analysis of individual patient data from studies investigating the value of antibiotics for acute rhinosinusitis.1 Combining the data from studies with similar patients, interventions, and outcomes can provide more precise estimates and thus resolve discussions with respect to contradicting outcomes of individual studies. Comparing the overall results for the odds ratio calculated in their “classic” meta-analysis with the individual patient data meta-analysis shows highly similar point estimates and CIs (1·35, 95% CI 1·15–1·59, and 1·37, 1·13–1·66, respectively), both significant. However, the number needed to treat (NNT) calculated from the individual patient data turns out to include the point of no effect, and thus is not significant. To our surprise, Young and colleagues do not address this discrepancy between the significant odds ratio and the non-significant NNT. For no apparent reason, they chose to give preference to the latter result in their Discussion. Moreover, the Summary only provides the NNT and ignores the odds ratio. For reasons of transparacy, we suggest that Young and colleagues provide their arguments for making the choice they did. Ideally, this choice should have been made in their research protocol.
Science Photo Library
many misused alcohol, were critically ill, and infected. All of these conditions are characterised by increased intestinal permeability and the effect is additive.5 Exposing an extremely leaky intestine to an additional bacterial load, albeit in apparently “friendly” probiotic form, seems to have led to severe intestinal damage. All intestinal bacteria have the potential to cause disease if they are in the wrong place. Probiotics should only be contemplated if the integrity of the gastrointestinal tract is not severely compromised: there are no “good” intestinal bacteria, only less harmful ones.
We declare that we have no conflict of interest.
*Johannes C van der Wouden, Sten P Willemsen [email protected] Department of General Practice, Erasmus Medical Center/University Medical Center, PO Box 2040, 3000 DR Rotterdam, Netherlands 1
Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a metaanalysis of individual patient data. Lancet 2008; 371: 908–14.
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