However, if the infection is more severe, watching and waiting is not advisable. Those patients have been excluded from most clinical trials by definition, he said.2 When we say patients get better on their own, those are patients who have to have mild sinusitis to have been included in the trials.
Explore This IssueOctober 2008
He added that physicians should not confuse the forgoing of antibiotics with no treatment at all. Just because you’re not giving the antibiotic doesn’t mean you aren’t treating, he stressed.
Some alternative effective remedies include saline irrigation, nasal steroids, and oral and topical decongestants. For saline irrigation, patients should use a solution of 1 teaspoon of salt per 8 ounces of water. The patient can then use a syringe to spray the solution up the nose. Nasal steroid sprays are equal to antibiotics in efficacy in mild sinusitis, Dr. Rosenfeld said.3 Nonprescription oral or topical decongestants can also help; in the case of topical decongestants, patients should not use them for more than three days, he stressed.
If patients are persistent about their desire for an antibiotic, education about antibiotic resistance may require some frankness. I tell the patient, you may feel better quicker, but if you get sick again, you will have more resistant bacteria that are tougher to treat, and this process will continue until you get a serious infection, Dr. Rosenfeld said. We would like to reserve antibiotics for more severe cases.
WASP and SNAP
A compromise can be the wait and see prescription (WASP). With WASP, the physician writes the prescription and gives it to the patient, but asks the patient to wait until seven days have passed or worsening occurs before filling the prescription. The physician can then ask the patient to consider letting the infection resolve naturally if he or she is getting better. Another term for this approach is the safety net antibiotic prescription (SNAP) (see sidebar).
People have been very receptive if you take the time to explain, Dr. Rosenfeld said. Unfortunately, with the pressures of managed care, WASP is not particularly a quick sell. That’s why physicians feel the pressure to just write the script. It doesn’t take that much time to explain WASP, though, and most patients are receptive, if they know the reasoning behind the wait.
He said that having antibiotics that work when we need them is a key motive behind WASP. It doesn’t serve anyone to create superbugs by treating mild infections with antibiotics, he said. If the patient is not comfortable with WASP, go ahead and use antibiotics, but at least have the conversation and give them the option. Use antibiotics only in those patients in whom you’ve made the right diagnosis. This approach makes it more likely to that you’ll use antibiotics more judiciously.
WASP and SNAP
Two acronyms, WASP and SNAP, have been used to describe the compromise approach in antibiotic treatment of sinusitis:
- Wait And See Prescription and
- Safety Net Antibiotic Prescription.
WASP and SNAP, which are identical approaches, can help the physician accommodate patient preferences and prudent use of antibiotics, said Richard M. Rosenfeld, MD, MPH. When exercising WASP/SNAP, the physician writes the prescription, but asks the patient to wait before filling it. The patient is asked to take the prescription to the pharmacy for filling only after either seven days with no improvement or worsening symptoms, even if seven days have not passed since the prescription was written.