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Postoperative antibiotics: preparing for the leap of faith

In their study, Lehmann et al directly confront the longstanding practice of prophylactic antibiotic use after endoscopic sinus surgery (ESS).1 This is a topic of perennial importance as the drive toward thoughtful antibiotic stewardship continues across the medical field.Within our specialty, a recent survey of the American Rhinologic Society membership found that 59% of respondents “always” prescribe antibiotics after ESS.2 Yet, despite the pervasiveness of this practice, a firm scientific basis has long been lacking. The findings from this double-blind, randomized, controlled trial indicate that placebo is no worse than a postoperative antibiotic (amoxicillin-clavulanate) with respect to patient-reported scores on the 22-item Sino-Nasal Outcome Test, nasal endoscopy findings, and postoperative infection rates.1 It is curious to note, as the authors highlight in their Discussion, that several major national and international medical bodies have already declared prophylactic antibiotics to be unnecessary after ESS. With the publication of this study, these recommendations are now supported by level 1 evidence. A key strength of this study is the litany of restrictive exclusion criteria, such as the presence of active intraoperative infection and the placement of a stent or packing during surgery. This limits the heterogeneity of participants and appropriately focuses the study on those who are truly receiving antibiotics prophylactically. The significance of this strategy cannot be understated. A cautionary analogy involves the state of evidence surrounding topical antibiotic therapy for chronic rhinosinusitis, the use of which has been recommended against by recent guidelines.3 A closer look reveals that the recommendation was derived from the findings of a small number of studies, the designs of which enrolled heterogeneous groups of all-comers who had ESS, rather than just those patients whowere most likely to benefit from the use of those antibiotics. Thus, it is unsurprising that topical antibiotics were not found to improve the clinical course of those study groups. When investigators enroll inappropriate subjects, they domore than skew the results of their specific studies— they also bias the practice parameters that ultimately derive from those studies.