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Acute Rhinosinusitis: When to Prescribe an Antibiotic

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Acute Rhinosinusitis: When to Prescribe an Antibiotic Pamela R. Hughes, MD; Carol H. Hungerford, DO; Acute rhinosinusitis: Kevin N. Jensen, DO Family Medicine Residency Clinic (Dr. Hughes) and When to prescribe an antibiotic Family Health Clinic (Dr. Hungerford), Mike O’Callaghan Military Medical Center, Las Vegas, Yes, the majority of antibiotics prescribed for acute NV; Ear Nose and Throat Specialists of Alaska, rhinosinusitis are unnecessary, but when should you Wasilla (Dr. Jensen) prescribe one and which one(s) should you use? pamela.r.hughes4.mil@ mail.mil The authors reported no potential conflict of interest relevant to this article. n estimated 30 million cases of acute rhinosinusitis PRACTICE The opinions and assertions (ARS) occur every year in the United States.1 More than contained herein are those RECOMMENDATIONS 80% of people with ARS are prescribed antibiotics in of the authors and are not to ❯ Reserve antibiotics for A be construed as official or as North America, accounting for 15% to 20% of all antibiotic pre- reflecting the views of the US Air patients who meet diagnostic scriptions in the adult outpatient setting.2,3 Many of these pre- Force Medical Department, the criteria for acute bacterial US Air Force at large, or the US scriptions are unnecessary, as the most common cause of ARS Department of Defense. rhinosinusitis (ABRS). 4,5 Patients must have purulent is a virus. Evidence consistently shows that symptoms of ARS nasal drainage that is will resolve spontaneously in most patients and that only those accompanied by either nasal patients with severe or prolonged symptoms require consider- obstruction or facial pain/ ation of antibiotic therapy.1,2,4,6 Nearly half of all patients will pressure/fullness and EITHER improve within 1 week and two-thirds of patients will improve symptoms that persist within 2 weeks without the use of antibiotics.7 In children, only without improvement for at about 6% to 7% presenting with upper respiratory symptoms least 10 days OR symptoms meet the criteria for acute bacterial rhinosinusitis (ABRS),8 that worsen within 10 days which we’ll detail in a bit. For most patients, treatment should of initial improvement consist of symptom management.5 (“double sickening”). A But what about the minority who require antibiotic ther- ❯ Offer watchful waiting apy? This article reviews how to evaluate patients with ARS, and delay antibiotics for up identify those who require antibiotics, and prescribe the most to 7 days after diagnosing appropriate antibiotic treatment regimens. ABRS in a patient if adequate access to follow- up is available; otherwise, treat with amoxicillin (with Diagnosis: Distinguishing or without clavulanate) viral from bacterial disease for 5 to 10 days. A ARS is defined as the sudden onset of purulent nasal discharge plus either nasal blockage or facial pressure/pain lasting Strength of recommendation (SOR) < 4 weeks.3,9 Additional signs and symptoms may include post- A Good-quality patient-oriented evidence nasal drip, a reduced sense of smell, sinus tenderness to palpa- B Inconsistent or limited-quality tion, and maxillary toothaches.10,11 patient-oriented evidence ARS may be viral or bacterial in etiology, with the most C Consensus, usual practice, opinion, disease-oriented common bacterial organisms being Streptococcus pneumoni- evidence, case series ae, Haemophilus influenzae, and Moraxella catarrhalis.1,3,5 The most common viral causes are influenza, parainfluenza, and rhinovirus. Approximately 90% to 98% of cases of ARS are vi- ral6,11; only about 0.5% to 2% of viral rhinosinusitis episodes are 244 THE JOURNAL OF FAMILY PRACTICE | JUNE 2020 | VOL 69, NO 5 complicated by bacterial infection.1,10-12 or lavage) was unilateral tenderness of the Diagnose ABRS when symptoms of ARS maxillary sinuses. The presence of purulent fail to improve after 10 days or symptoms of drainage in the nose or posterior pharynx ARS worsen within 10 days after initial im- also has significant diagnostic value, as it pre- provement (“double sickening”).1,11 Symp- dicts the presence of bacteria on antral aspi- toms that are significantly associated with ration.1 Purulent discharge in the pharynx is ABRS are unilateral sinus pain and reported associated with a higher likelihood of benefit maxillary pain. The presence of facial or den- from antibiotic therapy compared to placebo tal pain correlates with ABRS but does not (number needed to treat [NNT] = 8).16 How- identify the specific sinus involved.1 ever, colored nasal discharge indicates the There isn’t good correlation between pa- presence of neutrophils—not bacteria—and tients saying they have sinusitis and actually does not predict the likelihood of bacterial having it.13 A 2019 meta-analysis by Ebell et sinus infection.14,17 Therefore, the history and al14 reported that based on limited data, the physical exam should focus on location of overall clinical impression, fetid odor on the pain (sinus and/or teeth), duration of symp- breath, and pain in the teeth are the best in- toms, presence of fever, change in symptom dividual clinical predictors of ABRS. severity, attempted home therapies, sinus As recommended by the Infectious Dis- tenderness on exam, breath odor, and puru- ease Society of America (IDSA), a diagnosis lent drainage seen in the nasal cavity or pos- of ABRS is also reasonable in patients who terior pharynx.13,14 Approximately present with severe symptoms at the onset.6 ❚ Radiographic imaging has no role 90% to 98% of Although there is no consensus about what in the diagnosis or treatment of uncom- cases of acute constitutes “severe symptoms,” they are often plicated ABRS because viral and bacterial rhinosinusitis described as a temperature ≥ 102°F (39°C) etiologies have similar radiographic appear- are viral; only plus 3 to 4 days of purulent nasal drainage.1,4,6 ances. Additionally, employing radiologic about 0.5% Additional symptoms of ABRS may in- imaging would increase health care costs by to 2% of viral clude cough, fatigue, decreased or lack of at least 4-fold.5,6,8,17 The American Academy rhinosinusitis sense of smell (hyposmia or anosmia), and of Otolaryngology-Head and Neck Surgery episodes are ear pressure.10 Another sign of “double sick- (AAO-HNS) clinical practice guidelines rec- complicated ening” is the development of a fever after ommend against radiographic imaging for by bacterial several days of symptoms.1,9,15 Viral sinusitis patients who meet the diagnostic criteria for infection. typically lasts 5 to 7 days with a peak at days ABRS unless concern exists for a complica- 2 to 3.1,15 If symptoms continue for 10 days, tion or an alternate diagnosis is suspected.1 there is a 60% chance of bacterial sinusitis, Computed tomography (CT) imaging of the although some viral rhinosinusitis symptoms sinuses may be warranted in patients with se- persist for > 14 days.1,5 Beyond 4 to 12 weeks, vere headaches, facial swelling, cranial nerve sinusitis is classified as subacute or chronic.3 palsies, or bulging of the eye (proptosis), all of which indicate a potential complication of ABRS.1 Physical exam findings and the ❚ Laboratory evaluations. ABRS is a limited roles of imaging and labs clinical diagnosis; therefore, routine lab Common physical exam findings associated work, such as a white blood cell count, with the diagnosis of ABRS include altered C- reactive protein (CRP) level, and/or eryth- speech indicating nasal obstruction; edema rocyte sedimentation rate (ESR), are not or erythema of the skin indicating congested indicated unless an alternate diagnosis is capillaries; tenderness to palpation over the suspected.1,5,13,18,19 cheeks or upper teeth; odorous breath; and In one study, CRP > 10 mg/L and ESR purulent drainage from the nose or in the > 10 mm/h were the strongest individual pre- posterior pharynx. dictors of purulent antral puncture aspirate In a study by Hansen et al13 (N = 174), the or positive bacterial culture of aspirate, which only sign that showed significant association is considered diagnostic for ABRS. 20 However, with ABRS (diagnosed by sinus aspiration CRP and ESR by themselves are not adequate MDEDGE.COM/FAMILYMEDICINE VOL 69, NO 5 | JUNE 2020 | THE JOURNAL OF FAMILY PRACTICE 245 TABLE 1 Diagnostic criteria for acute bacterial rhinosinusitis AAO-HNS1 ARS symptoms (purulent nasal discharge plus either nasal obstruction or facial pain/pressure) plus 1 of the following: Persistent symptoms for 10 days after onset without improvement OR Acute worsening of symptoms after an initial improvement (“double sickening”) IDSA6 Presence of ARS symptoms with any of the following: • Severe features (temperature ≥ 102ºF [39ºC] and facial pain) for at least 3 days • “Double sickening” • Persistent and not improving symptoms for at least 10 days AAO-HNS, American Academy of Otolaryngology-Head and Neck Surgery; ARS, acute rhinosinusitis; IDSA, Infectious Diseases Society of America. to diagnose ABRS.20 This study developed a ARS and ABRS is recommended as first-line clinical decision rule that used symptoms, therapy; it should be offered to patients before signs, and laboratory values to rate the likeli- making a diagnosis of ABRS.1,5,9,25 Consider hood of ABRS as being either low, moderate, using analgesics, topical intranasal steroids, or high. However, this clinical decision rule and/or nasal saline irrigation to alleviate has not been prospectively validated. symptoms and improve quality of life.1,5,25 In- Thus, CRP and ESR elevations can sup- terventions with questionable or unproven port the diagnosis of ABRS, but the low sen- efficacy
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