Scheid pt 2.pdf

Acute Bacterial Rhinosinusitis in Adults:
Part II. Treatment
DEWEY C. SCHEID, M.D., M.P.H., and ROBERT. M. HAMM, PH.D.
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
Although most cases of acute rhinosinusitis are caused by viruses, acute bacterial rhinosinusitis
is a fairly common complication. Even though most patients with acute rhinosinusitis recover
promptly without it, antibiotic therapy should be considered in patients with prolonged or
more severe symptoms. To avoid the emergence and spread of antibiotic-resistant bacteria, nar-
row-spectrum antibiotics such as amoxicillin should be used for 10 to 14 days. In patients with
mild disease who have beta-lactam allergy, trimethoprim/sulfamethoxazole or doxycycline are
options. Second-line antibiotics should be considered if the patient has moderate disease, recent
antibiotic use (past six weeks), or no response to treatment within 72 hours. Amoxicillin-clavu-
lanate potassium and fluoroquinolones have the best coverage for Haemophilus influenzae and
Streptococcus pneumoniae. In patients with beta-lactam hypersensitivity who have moderate
disease, a fluoroquinolone should be prescribed. The evidence supporting the use of ancillary
treatments is limited. Decongestants often are recommended, and there is some evidence to
support their use, although topical decongestants should not be used for more than three days
to avoid rebound congestion. Topical ipratropium and the sedating antihistamines have anticho-
linergic effects that may be beneficial, but there are no clinical studies supporting this possibility.
Nasal irrigation with hypertonic and normal saline has been beneficial in chronic sinusitis and
has no serious adverse effects. Nasal corticosteroids also may be beneficial in treating chronic
sinusitis. Mist, zinc salt lozenges, echinacea extract, and vitamin C have no proven benefit in
the treatment of acute bacterial rhinosinusitis. (Am Fam Physician 2004;70:1697-704,1711-12.
Copyright 2004 American Academy of Family Physicians.)
In this article, the evidence supporting different treatments for acute bacterial part one1 of this two-part article, clinical RESULTS OF CLINICAL TRIALS
criteria for evaluating ABRS are described. There have been no randomized controlled ▲ Patient informa-
trials (RCTs) of antibiotic treatment for ABRS tion: A handout on sinus
Antibiotics
using sinus aspirate cultures before and after About two thirds of patients with ABRS treatment, although nonrandomized trials authors of this article, is provided on page 1711.
improve without antibiotic treatment, have demonstrated bacteriologic cures. Five and most patients with viral upper respi- RCTs and two meta-analyses have compared See page 1621 for definitions of strength-of- ratory infection (URI) improve within antibiotics, usually amoxicillin and trim- seven days.2 Antibiotic therapy should be ethoprim-sulfamethoxazole (TMP-SMX; reserved for patients who have Bactrim, Septra), with placebo, with clini-had symptoms for more than cal improvement as the outcome, which is Antibiotic therapy should be
seven days and who present the more clinically relevant patient-oriented reserved for use in patients
outcome.4,5 About 47 percent of patients who have had symptoms
teria for ABRS (purulent nasal treated with antibiotics and 32 percent of the for more than seven days
discharge, maxillary tooth or control group were cured at 10 to 14 days. and who meet two or more
Eighty-one percent of patients treated with clinical criteria for acute bac-
lateral], unilateral maxillary antibiotics and 66 percent of the control terial rhinosinusitis.
group were cured or improved, meaning one ing symptoms after initial patient benefited for every seven treated with November 1, 2004 ◆ Volume 70, Number 9 American Family Physician 1697
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Diagnosis and Management of Acute Bacterial Rhinosinusitis
in Immunocompetent Adults
Initial evaluation of upper respiratory symptoms: duration of symptoms > 7 days and ≤ 4 weeks; positive findings (at least 2): • Purulent nasal discharge • Maxillary tooth or facial pain (especially unilateral) • Unilateral maxillary sinus tenderness • Worsening symptoms after initial improvement • Periorbital swelling• Severe facial or dental pain• Altered mental status• Diplopia Recent (within six weeks) use of antibiotics? Prevalence of resistant organisms > 30 percent? Additional evaluation and treatment: • Extended antibiotic treatment 10 to 14 days (depending on the drug) • Further evaluation of underlying risk factors• Consider sinus imaging Refractory subacute and/or recurrent sinusitis:• Individualize medical therapy• Consider sinus imaging• Consider opportunistic infections, immunodeficiency, structural abnormalities• Consider referral to allergist or otolaryngologist for evaluation Figure 1. Algorithm for diagnosis and management of acute bacterial rhinosinusitis in immuno-
antibiotics. The treatment effect in these tri- rates—generally above 85 percent. The use of als may have been underestimated because fluoroquinolones for ABRS is relatively new. the lack of specificity of diagnosis diluted the Ciprofloxacin (Cipro) and cefuroxime had effect of treatment.
90 percent resolution rates when adminis- tered to patients in a primary care setting.8 In mentin), cephalosporins (cefuroxime [Cef- an open-label RCT, levofloxacin (Levaquin) tin] and cefixime [Suprax]), and macrolides and clarithromycin had 96 and 93 percent (azithromycin [Zithromax] and clarithromy- cin [Biaxin]), have been studied extensively.6,7 All have demonstrated similar clinical success past seven years concluded that newer broad- 1698 American Family Physician
Volume 70, Number 9 ◆ November 1, 2004 Bacterial Rhinosinusitis
spectrum antibiotics are no more effective Although lacking complete H. influenzae than narrow-spectrum antibiotics.4,5,10,11 In coverage, amoxicillin is still a good choice most of these studies, amoxicillin was com- for a first-line antibiotic in community- pared with a cephalosporin, a fluoroquino- lone, or a macrolide. The rapid emergence of with resistant organisms improve anyway,18 antibiotic-resistant organisms associated with and because it is well tolerated and inex-ABRS has made choosing an antibiotic more pensive (Table 1).13-16 Higher daily doses of difficult. Surveillance studies have shown amoxicillin (3 to 4 g per day) may be neces-an increasing prevalence of antibiotic-resis- sary in areas with a high prevalence of peni- tant Streptococcus pneumoniae.12,13 Up to 25 cillin-resistant S. pneumoniae. TMP-SMX percent of these bacteria are penicillin resis- and doxycycline are alternatives for use in tant, and 15 percent are penicillin interme- patients who are allergic to beta lactams, but diate. Resistance to macrolides, doxycycline they have limited coverage for H. influenzae (Vibramycin), and TMP-SMX is common.12 and S. pneumoniae, and failure rates of up The prevalence of beta-lactamase–producing to 25 percent are possible.16 Erythromycin, Haemophilus influenzae is about 30 percent, second-generation cephalosporins with less and resistance to TMP-SMX is common.12 activity against H. influenzae (e.g., cefa-Nearly all Mycobacterium catarrhalis isolates clor [Ceclor], cefprozil [Cefzil], loracarbef produce beta-lactamase.
[Lorabid]), and tetracycline should not be used to treat ABRS.19 SELECTING AN ANTIBIOTIC
Although the cephalosporins (cefpodoxime To integrate current antibiotic resistance [Vantin], cefuroxime, cefdinir [Omnicef], surveillance data into antibiotic recom- ceftriaxone [Rocephin]) and amoxicillin/cla- mendations, the Sinus and Allergy Health vulanate potassium also have been recom-Partnership (SAHP) used the Poole Thera- mended for initial treatment,16 any benefit of peutic Outcomes Model, a mathematical these agents as initial therapy must be bal-model that predicts clinical efficacy for each anced against their much higher cost and con-of the antibiotics commonly prescribed for cerns about increasing antibiotic resistance in ABRS (Table 1).13-16 The model incorporates the community. A retrospective cohort study assumptions about the probability of bacte- of a pharmaceutical database of 29,000 adults rial infection, pathogen distribution, sponta- with ABRS showed equivalent success rates neous resolution rates, and in vitro activity of with the use of older, inexpensive antibiot-antibiotics.15 ics at one half the cost.20 A cost-effectiveness When choosing antibiotic therapy for analysis showed that even if more expensive ABRS, physicians should consider recent agents were 23 percent more effective than antibiotic use, efficacy, and cost. The SAHP amoxicillin, using them empirically would guidelines classify patients with ABRS into be cost effective only if the prevalence of two groups to determine initial treatment: true bacterial sinusitis in treated patients was (1) those with mild symptoms who have not greater than 80 percent.21received antibiotics within six weeks and (2) Second-line antibiotics should be consid- those who have moderately severe disease or ered when the patient has moderate disease, have received antibiotics within six weeks.16 has used antibiotics in the past six weeks, Patients with moderate disease are considered or has no response to treatment within less likely to have spontaneous resolution and 72 hours. Amoxicillin-clavulanate potas-thus have a higher rate of treatment failure. sium and fluoroquinolones (gatifloxacin The guidelines offer no criteria for severity. [Tequin], levofloxacin, and moxifloxacin The categorization of moderate or mild sever- ity is left to the physician’s clinical judgment, age for H. influenzae and S. pneumoniae. but an example was offered with earlier rec- Other choices include intramuscular ceftri- axone or combination therapies including high-dose amoxicillin; clindamycin (Cleo- November 1, 2004 ◆ Volume 70, Number 9 American Family Physician 1699
TABLE 1
Oral Antibiotics Used in the Treatment of Acute Bacterial Rhinosinusitis
Mild disease and no recent
antibiotic use
Amoxicil in-clavulanate
Moderate disease or
recent antibiotic use
Gatifloxacin (Tequin)
Amoxicil in-clavulanate (high 2,000 mg every 12 hours§ TMP-SMX = trimethoprim-sulfamethoxazole. *—Clinical efficacy based on calculation from the Poole Therapeutic Outcomes Model.15†—Estimated cost to the pharmacist based on average wholesale prices in Red book. Montvale, N.J.: Medical Economics Data, 2004. Cost to the patient will be higher, depending on prescription fil ing fee. Cost is for 10 days of therapy, unless stated otherwise.
‡—Any benefit of these agents as initial therapy must be balanced against their much higher cost and concerns about increasing antibiotic resistance.
§—Based on amoxicil in component.
||—Cost is for five days of therapy, including injection fee.
¶—Combination therapies include high-dose amoxicil in or clindamycin plus cefixime or high-dose amoxicil in or clindamycin plus rifampin.16**—Provides coverage for Streptococcus pneumoniae but has no activity against Haemophilus influenzae. Information from references 13 through 16. 1700 American Family Physician
Volume 70, Number 9 ◆ November 1, 2004 Bacterial Rhinosinusitis
cin) plus cefixime; or high-dose amoxicillin or clindamycin plus rifampin (Rifadin).16 In patients with a history of beta-lactam Ancillary Treatment for Acute Bacterial Rhinosinusitis
allergies, the use of fluoroquinolones or combination therapy with clindamycin and Likely to be effective
DURATION OF TREATMENT
Most clinical trials have used 10- to 14-day courses of antibiotic therapy. Sinus puncture in at least 95 percent of patients after a 10-day course of antibiotics.22 Results of one study showed no differences in clinical or Possibly effective
radiographic improvement between patients receiving three- or 10-day courses of TMP- SMX.23 However, this study was conducted before 1995, and microbial resistance pat- terns have changed since then. More recently, five-day treatment courses with azithromycin and telithromycin (Ketek) were found to be TREATMENT FAILURE
When a patient fails to respond to therapy, No proven benefit
additional history, physical examination, cul- tures, or imaging may be necessary. If a change in antibiotic therapy is made, the limitations in coverage of the initial antibiotic should be considered. A switch to a fluoroquinolone is recommended after failure of amoxicillin or doxycycline.16 Combination therapy may be advantageous, particularly in patients previ- *—Although topical decongestants are effective, use must be limited to three days ously treated with cefdinir or macrolides.
to avoid rebound congestion.
†—Often combined with an oral decongestant.
‡—Dosage varies by drug. Ancillary Treatment
Information from references 26 through 48. The evidence supporting the use of ancil-lary treatment for ABRS is relatively weak (Table 2).26-48 Some studies show improve- patients, but reduced mucosal blood flow ment in symptoms, but no treatments have may increase inflammation.30 Topical decon-been shown to affect the duration of ill- gestants should not be used longer than three ness.26-28 Oral decongestants can be used until days to avoid rebound vasodilation.
symptoms resolve. In patients with stable hypertension, decongestants have not been antihistamines for treatment of patients shown to seriously increase blood pressure.29 with ABRS. Even though histamine does Decongestants should be used with caution not play a role in this infectious condition in patients with ischemic heart disease, glau- except, possibly, in patients who also have a predisposing allergic rhinitis, these drugs Although topical decongestants have been have some anti-inflammatory effects that advocated in the past, their use is more con- may be beneficial.31 However, the anticho- troversial. Symptoms are improved in some linergic effects of first-generation antihista- November 1, 2004 ◆ Volume 70, Number 9 American Family Physician 1701
mines could impair clearance by thickening cal xylometazoline (Otrivin) for three days. mucus.31 Newer second-generation antihis- Patients who received fluticasone showed tamines have little or no anticholinergic more rapid improvement (6.0 versus effect and may have a role in treatment of 9.5 days) than patients who received placebo.
patients with allergy and chronic sinusitis, Nasal saline spray, nasal irrigation, and mist humidification have been recommended The topical anticholinergic agent ipratro- in the past to promote mucociliary clearance pium bromide (Atrovent) has been used to by decreasing congestion, moistening the decrease rhinorrhea in patients with the nasal cavity, and removing crusty mucus.31 common cold,32 but there are no studies in Most trials have been small, many were not patients with ABRS. Theoretically, ipratro- controlled, and methods varied, so evidence pium may increase the viscosity of mucus supporting their use is only fair.27,28,38 Saline and impair its clearance, but this effect irrigation is safe, and there are no docu-appears to be less prominent with ipratro- mented serious adverse effects.38 Hypertonic Most studies of intranasal steroids in decreased medication use in patients with patients with ABRS have not shown an effect chronic sinusitis.39,40 Saline sprays have been on clinical outcomes. These studies often shown to reduce symptoms of rhinitis,41 but were underpowered and included patients there are no studies in patients with ABRS. who had chronic sinusitis and nasal poly- Controlled studies of mist use in URI have posis, as well as ABRS.33-36 A recent RCT,37 not shown a benefit.42,43limited to patients with a history of pre- Guaifenesin (Hytuss), a mucolytic agent, vious recurrent or chronic sinusitis, com- pared fluticasone (Flovent) with placebo ning secretions, but there is no evidence of in the treatment of patients with ABRS. clinical benefit. An RCT showed no effect on Both groups received cefuroxime and topi- mucociliary clearance in healthy subjects.44 However, guaifenesin did reduce nasal con-gestion in an RCT of patients infected with Indications for Referral in Patients
with Bacterial Rhinosinusitis
mend the use of vitamin C, zinc salt loz- Findings of severe acute bacterial rhinosinusitis enges, or echinacea in patients with ABRS. Using the outcome of cold symptoms after Periorbital cel ulitisIntracranial abscess seven days, a meta-analysis of eight clini- cal trials of zinc salt–lozenge treatment for the common cold did not find a significant Pott’s puffy tumor (infectious erosion of the benefit (odds ratio, 0.50; 95 percent confi- dence interval, 0.19 to 1.29).46 Several trials of echinacea extract in the treatment of the Treatment failure after extended course of common cold reported a mild benefit, but each trial had serious methodologic flaws. A recent RCT of echinacea in college students Nosocomial infectionsImmunocompromised host Complications and Referral
Biopsy to rule out granulomatous disease, Patients with complications or treatment fail- ure after extended antibiotic therapy should Evaluation for immunotherapy of al ergic rhinitis be referred to an otolaryngologist (Table 3).6,48 Information from references 6 and 48. Patients who are referred to otolaryngologists usually are evaluated with nasal endoscopy 1702 American Family Physician
Volume 70, Number 9 ◆ November 1, 2004 Bacterial Rhinosinusitis
Strength of Recommendations
Key clinical recommendation
References
Amoxicil in for 10 to 14 days is a reasonable first-line agent.
In patients with mild disease who have beta-lactam hypersensitivity, trimethoprim-sulfamethoxazole (Bactrim, Septra) or doxycycline (Vibramycin) are reasonable, cost-effective, first-line options.
In patients with moderate disease, recent antibiotic use, or lack of treatment C response within 72 hours, amoxicil in-clavulanate potassium (Augmentin) or a fluoroquinolone should be prescribed.
Ancil ary treatments such as decongestants, topical anticholinergics, guaifenesin (Hytuss), saline nasal irrigation, and nasal corticosteroids may Mist, zinc salt lozenges, echinacea, and vitamin C have no proven benefit.
Patients with complications or treatment failure after extended antibiotic therapy should be referred to an otolaryngologist. Patients with frequent recurrences of acute bacterial rhinosinusitis and inadequately control ed al ergic rhinitis should be referred to an al ergist for consideration of immunotherapy.
and a sinus computed tomographic scan. 7. Low DE, Desrosiers M, McSherry J, Garber G, Wil iams Patients with frequent recurrences of ABRS JW Jr, Remy H, et al. A practical guide for the diagnosis and treatment of acute sinusitis. CMAJ 1997;156(suppl and inadequately controlled allergic rhinitis should be referred to an allergist for consider- 8. Weis M, Hendrick K, Til otson G, Gravel e K. Multi- center comparative trial of ciprofloxacin versus cefu-roxime axetil in the treatment of acute rhinosinusitis Members of various medical faculties develop articles for in a primary care setting. Rhinosinusitis Investigation “Practical Therapeutics.” This article is one in a series coordinated by the Department of Family and Preventive 9. Kahn JB, Riel y-Bauvin K, Demartin EL, et al. Multi- Medicine at University of Oklahoma Health Sciences center, open-label, randomized study to compare the Center, Tulsa, Okla. Coordinator of the series is John safety and efficacy of oral levofloxacin and Biaxin in the treatment of acute maxil ary sinusitis in adults. Abstracts from the Proceedings of the 35th Annual The authors indicate that they do not have any conflicts Meeting of the IDSA, San Francisco, September 13-18, 1997. Abstract 578.
of interest. Sources of funding: none reported. 10. De Bock GH, Dekker FW, Stolk J, Springer MP, Kievit J, van Houwelingen JC. Antimicrobial treatment in acute maxil ary sinusitis: a meta-analysis. J Clin Epidemiol REFERENCES
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