Antibiotics not needed after sinus surgery: latest study

Prophylactic use of antibiotics after endoscopic sinus surgery (ESS) did not reduce infection rates nor improve sinus symptoms, yet was associated with increased gastrointestinal side effects, according to a randomized study — indicating that antibiotics are not necessary after most sinus surgeries.

“Surgeons commonly prescribe prophylactic antibiotics after ESS, yet minimal data exist to support this practice,” the researchers pointed out. 

In the double-blind, noninferiority trial, 77 adults (mean age 44.1 years, 35 percent female) with chronic rhinosinusitis were randomized 1:1 to receive the broad-spectrum antibiotic amoxicillin-clavulanate or placebo for a week after undergoing ESS. [Int Forum Allergy Rhinol 2020;doi:10.1002/alr.22756]

The researchers found that placebo was noninferior to prophylactic antibiotics in improving symptoms after surgery, as measured using the SNOT-22* questionnaire (p<0.05).

There were also no significant differences in endoscopic scores between the two groups, as indicated by changes in the Lund-Kennedy score trajectories over time (p=0.63).

“Postoperative prophylactic antibiotics had no significant effect on participants’ postoperative sinonasal-specific QOL** or endoscopic scores, regardless of the severity of their preoperative imaging or whether they had nasal polyps, asthma, a history of ESS, or growth on their operative cultures,” the researchers reported.

In addition, no benefit was seen in terms preventing infections after surgery, with the antibiotic group experiencing similar infection rates as the placebo group postoperatively (2.6 percent vs 2.4 percent; relative risk [RR], 1.08; p=0.96).

However, diarrhoea occurred tenfold more frequently in patients who took antibiotics than those on placebo (24.3 percent vs 2.5 percent; RR, 10.8; p=0.02).  

"For routine sinus surgery, antibiotics are unnecessary and may cause more complications like gastrointestinal side effects" said study principal investigator Professor Eric Holbrook of Harvard Medical School in Boston, Massachusetts, US.

“Our findings suggest that otolaryngologists can rethink the practice of routinely prescribing antibiotics after ESS,” said study co-author Dr Stacey Gray, also from Harvard Medical School.

According to the authors, widespread prescription of prophylactic antibiotics after ESS persists despite advice against such use by international guidelines, including those from the WHO and the US CDC***.    

“These recent national and international guidelines recommend a single dose of prophylactic antibiotic administered immediately before surgery for some types of surgery but do not recommend any routine postoperative antibiotic prophylaxis,” observed the researchers.

“Antibiotics should still be considered when the benefits outweigh the risks, including complex surgical procedures are performed or if the patient is at greater risk for developing an infection,” advised Gray. “Postoperative prophylactic antibiotics may be considered when nasal packing is placed due to the concern for toxic shock syndrome.”

As only about half (57.5 percent) of the initially planned number of participants completed the trial, the study was statistically underpowered to draw definitive conclusion on noninferiority — which constitutes a major limitation. Nonetheless, the findings were consistent across subgroups throughout the study, thus adding strength to the data, the researchers noted.

“Even short-term oral antibiotic courses carry well-established risks beyond the observed side effect of diarrhoea, including the selection of resistant bacteria, antibiotic-related allergic reactions, and Clostridioides difficile-associated infections,” they added.