Don't Use Amox-Clav When Amox (or Nothing) Will Do
In acute sinusitis, we need more "nothing".
This is a big ol’ MarketScan database data dredge of patients prescribed either amoxicillin-clavulanic acid or amoxicillin for the treatment of acute sinusitis. The “importance” here is that the Infectious Diseases Society of America recommends amoxicillin-clavulanic acid over amoxicillin, whilst the American Academy of Otolaryngology–Head and Neck Surgery gives no specific preference.
The preponderance of evidence now, in adults and children, is that plain amoxicillin ought to be the first choice:
Out of ~500,000 eligible encounters, ~400,000 received amoxicillin-clavulanic acid, and the results above show propensity score-matched cohorts. No reliable detectable differences in treatment failure, but amoxicillin-clavulanic acid gave rise to more downstream cases of yeast infections and Clostridium difficile.
But, not mentioned at all in this article: it’s likely most of these cases never needed anything more than time and conservative therapy. A clear reason it’s not possible to show a difference in outcomes between two therapies is when the natural course of the disease is to cure, regardless. Without stricter criteria for failure of conservative management and initiation of antibiotics in sinusitis, we can’t truly ask the question whether there is a difference in efficacy between these two agents.
At the least, however, if we can’t stop prescribing unnecessary antibiotics – prescribe the less harmful one.