Acute and Chronic Sinusitis

Question 1

What are risk factors for Antibiotic resistance in Acute bacterial rhinosisusitis

Answer 1

• Age <2 and >65
• Prior ABs in the last month
• Prior hospitalization in past 5 days
• Comorbidities
• Immunocompromised.

Question 2

What are the 3 clinical presentations for identifying patients with acute bacterial vs. Viral rhinosinusitis? Any of these three count

Answer 2

1. Onset with persistent symptoms or signs compatible with acute rhinosinusitis, lasting for ≥10 days without any evidence of clinical improvement (strong, low-moderate);
2. Onset with severe symptoms or signs of high fever (≥39°C [102°F]) and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness (strong, low-moderate); or
4. Onset with worsening symptoms or signs characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection (URI) that lasted 5–6 days and were initially improving (“double-sickening”)

Question 3

Should Amoxicillin or Amox/clav be used for initial emperic therapy of ABRS in adults and children?

Answer 3

Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in adults (weak, low).

The recommendation that amoxicillin-clavulanate rather than amoxicillin alone be considered as first-line therapy for ABRS is based on 2 observations: (1) the increasing prevalence of H. influenzae among other upper respiratory tract infections of children, particularly AOM, since the introduction of conjugated pneumococcal vaccines [84]; and (2) the high prevalence of β-lactamase–producing respiratory pathogens in ABRS (particularly H. influenzae and Moraxella catarrhalis) among recent respiratory tract isolates

Question 4

When is high dose Amox/clav recommended during initial Emperic antimicrobial therapy for ARBS in Children or adults?

Answer 4

“High-dose” (2 g orally twice daily or 90 mg/kg/day orally twice daily) amoxicillin-clavulanate is recommended for children and adults with ABRS:
1. from geographic regions with high endemic rates (≥10%) of invasive penicillin-nonsusceptible (PNS) S. pneumoniae,
2. those with severe infection (eg, evidence of systemic toxicity with fever of 39°C [102°F] or higher,
3. and threat of suppurative complications), attendance at daycare, age <2 or >65 years, recent hospitalization, antibiotic use within the past month, or who are immunocompromised (weak, moderate).

Question 5

Should a respiratory FQ vs. a B-lactam agent be used as first line agents for the initial Emperic therapy for ARBS?

Answer 5

Betalactam (Amox/clav) is preferred over FQs

Question 6

Besides a Respiratory Fluoroquinolone, Should a Macrolide, Trimethoprim-Sulfamethoxazole, Doxycycline, or a Second- or Third-Generation Oral Cephalosporin Be Used as Second-line Therapy for ABRS in Children or Adults?

Answer 6

7. Macrolides (clarithromycin and azithromycin) are not recommended for empiric therapy due to high rates of resistance among S. pneumoniae (∼30%) (strong, moderate).
8. Trimethoprim-sulfamethoxazole (TMP/SMX) is not recommended for empiric therapy because of high rates of resistance among both S. pneumoniae and Haemophilus influenzae (∼30%–40%) (strong, moderate).
9. Doxycycline may be used as an alternative regimen to amoxicillin-clavulanate for initial empiric antimicrobial therapy of ABRS in adults because it remains highly active against respiratory pathogens and has excellent pharmacokinetic/pharmacodynamic (PK/PD) properties (weak, low).
10. Second-and third-generation oral cephalosporins are no longer recommended for empiric monotherapy of ABRS due to variable rates of resistance among S. pneumoniae. Combination therapy with a third-generation oral cephalosporin (cefixime or cefpodoxime) plus clindamycin may be used as second-line therapy for children with non–type I penicillin allergy or from geographic regions with high endemic rates of PNS S. pneumoniae

Surveillance data from the TRUST (Tracking Resistance in the United States Today) and PROTEKT (Prospective Resistant Organism Tracking and Epidemiology of the Ketolide Telithromycin) studies reveal that whereas only 5% of S. pneumoniae clinical isolates in the United States were resistant to macrolides in 1993, >30% had become resistant by 2006 [117].
Harrison et al [94] evaluated the susceptibility to common pediatric antibiotics among S. pneumoniae, nontypeable H. influenzae, and M. catarrhalis isolated from 2005 through 2007. TMP/SMX resistance rates according to CLSI breakpoints were 50% for S. pneumoniae (75% for serotype 19A), 27% for H. influenzae, and 2% for M. catarrhalis (73% according to PK/PD breakpoints). Resistance to TMP/SMX among S. pneumoniae isolates is due to mutations in the dihydrofolate reductase gene [121], and is strongly associated with prior exposure to TMP/SMX, macrolides, or penicillin [117]. Not surprisingly, TMP/SMX resistance rates are significantly higher (>80%) among macrolide- or penicillin-resistant S. pneumoniae [122]. Similarly, among H. influenzae isolates collected during 2001–2005 in the TRUST program, resistance rates to TMP/SMX was 25%

Question 7

Which Antimicrobial Regimens Are Recommended for the Empiric Treatment of ABRS in Adults and Children With a History of Penicillin Allergy?

Answer 7

a. ADULTS: Either doxycycline (not suitable for children) or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) is recommended as an alternative agent for empiric antimicrobial therapy in adults who are allergic to penicillin (strong, moderate).

b. Children: Levofloxacin is recommended for children with a history of type I hypersensitivity to penicillin; combination therapy with clindamycin plus a third-generation oral cephalosporin (cefixime or cefpodoxime) is recommended in children with a history of non–type I hypersensitivity to penicillin (weak, low).

Question 8

Should Coverage for Staphylococcus aureus (Especially Methicillin-Resistant S. aureus) Be Provided Routinely During Initial Empiric Therapy of ABRS?

Answer 8

No, even though it is a potential pathogen.

Question 9

How long do we treat for in adults and kids for ABRS

Answer 9

Adults - 5 to 7 days
Children - 10-14

Question 10

Is Saline Irrigation of the Nasal Sinuses of Benefit as Adjunctive Therapy in Patients With ABRS?

Answer 10

Yes in adults

Question 11

Should intranasal corticosteroids be adjunct treatment in ABRS?

Answer 11

Yes, primarily in patients with a history of allergic rhinitis.

Question 12

Should Topical or Oral Decongestants or Antihistamines Be Used as Adjunctive Therapy in Patients With ABRS?

Answer 12

No

Question 13

How Long Should Initial Empiric Antimicrobial Therapy in the Absence of Clinical Improvement Be Continued Before Considering Alternative Management Strategies?

Answer 13

An alternative management strategy is recommended if symptoms worsen after 48–72 hours of initial empiric antimicrobial therapy or fail to improve despite 3–5 days of initial empiric antimicrobial therapy (strong, moderate).

Question 14

What Is the Recommended Management Strategy in Patients Who Clinically Worsen Despite 72 Hours or Fail to Improve After 3–5 Days of Initial Empiric Antimicrobial Therapy With a First-line Regimen?

Answer 14

Patients who clinically worsen despite 72 hours or fail to improve after 3–5 days of empiric antimicrobial therapy with a first-line agent should be evaluated for the possibility of resistant pathogens, a noninfectious etiology, structural abnormality, or other causes for treatment failure (strong, low).

Question 15

How to get sinus cultures in patients who have failed to respond to empiric first line and second line agents?

Answer 15

21. It is recommended that cultures be obtained by direct sinus aspiration rather than by nasopharyngeal swab in patients with suspected sinus infection who have failed to respond to empiric antimicrobial therapy (strong, moderate).
22. Endoscopically guided cultures of the middle meatus may be considered as an alternative in adults, but their reliability in children has not been established (weak, moderate).
23. Nasopharyngeal cultures are unreliable and are not recommended for the microbiologic diagnosis of ABRS (strong, high).

Question 16

What is the most frequent cause of acute Rhinosinusitis?

Answer 16

Viral cold, or common cold

Question 17

What is the % chance of developing bacterial infection with acute rhinosinusitis?

Answer 17

2-10% (Viruses are 90-98%)

Question 18

What are the conventional critieria and major symptoms for the diagnosis of sinusitis (Based on the presence of at least 2 major and 1 major and >2 minor symotoms.)

Answer 18

Major symptoms:
- Purulent anterior nasal discharge
- Purulent or discolored posterior nasal discharge
- Nasal congestion or obstruction
- facial congestion or fullness
- Facial pain or pressure
- Hyposmia or anosmia
- Fever

Minor symptoms:
- Headache
- ear pain or pressure
- Halitosis
- dental pain
- cough
- fever
- Fatigue

Question 19

Is CT good for diagnosing ABRS?

Answer 19

NO! Most people have abnormalities in sinus passages

Question 20

Should AB be held if a diagnosis of ABRS is made?

Answer 20

Because adoption of more stringent clinical criteria based on characteristic onset and clinical presentations is more likely to identify patients with bacterial rather than acute viral rhinosinusitis, withholding or delaying empiric antimicrobial therapy is not recommended. Prompt initiation of antimicrobial therapy as soon as the clinical diagnosis of ABRS is established as defined in recommendation 1 should shorten the duration of illness, provide earlier symptomatic relief, restore quality of life, and prevent recurrence or suppurative complications

Question 21

What is the definition of ABRS?

Answer 21

ABRS is defined as symptomatic inflammation of the paranasal sinuses and nasal cavity that is less than 4 weeks

Question 22

What is chronic rhinosinusitis defined as?

Answer 22

Chronic rhinosinusitis (CRS) if lasting more than 12 weeks, with or without acute exacerbations

Question 23

Describe the pathophysiology of ABRS?

Answer 23

ABRS is often preceded by a viral infection that causes mucosal inflammation and obstruction of the sinus ostia—the conduits that drain the sinuses.3 Mucosal secretions are trapped, local defenses are impaired, and bacteria from neighbouring surfaces begin to grow. The maxillary and ethmoid sinuses are most frequently involved.

Question 24

What are the differences between the discharge in viral vs. Bacterial RS?

Answer 24

The nasal discharge in viral sinusitis is classically clear and thin, whereas in bacterial sinusitis it is yellow-green and thick.

Question 25

Which patients should be immediately referred?

Answer 25

high, persistent fevers >39°C; swelling, inflammation, or redness around the eyes; cranial nerve palsies; abnormal extraocular movements; proptosis (bulging of one or both of the eyes); vision changes (double vision or impaired vision); severe headache; altered mental status; or meningeal signs should be referred immediately as this may be a complicated ARBS.

Question 26

What are the typical symptoms of ABRS in children?

Answer 26

In children to have an uncomplicated ABRS you have to have:

Symptoms and signs indicating sinus infection (daytime cough, nasal symptoms, or both), and
ARS that appears to be bacterial as opposed to viral, including:
Symptoms present without improvement for >10 and <30 days, or
Severe symptoms (ill appearance, temperature ≥39°C , and purulent nasal discharge for ≥3 consecutive days), or
Symptoms that worsen (new onset of severe headache or fever, or recurrence of fever after initial improvement, more respiratory symptoms)

Children with untreated ARBS are at risk for serious complications.12 This in fact may be how they originally present.

Question 27

What are the most common bacterial causes of ABRS?

Answer 27

S. pneumoniae and H. influenzae are the most common causes of ABRS

(35% for both in adults, 41% for SP and 29% HI in children). M. catarrhalis (2% in adults, 26% in children), less commonly, S. aureus, S. pyogenes, fungi and anaerobes.

Question 28

What is the First line and second line treatment for ABRS?

Answer 28

Question 29

Can we use decongestants and antihistamines?

Answer 29

Ideall no, however, if congestion is unbearable, a nasal decongestant is acceptable for 3 to 5days, and only in those >12 yrs old.

Question 30

What to do if first, second therapies fail?

Answer 30

If symptoms persist or worsen after 48 to 72 hours of antibiotic therapy, then the patient should be reassessed, and alternative antibiotics should be considered. Patients should respond to a second course of appropriate antibiotic therapy within 7 days. If they fail this treatment course, they should be referred for specialist reviewing. Patients who do not respond to first- or second-line therapies should be referred to a specialist and evaluated more aggressive

Question 31

What are the subtypes of Chronic Rhinosinusitis?

Answer 31

CRS with polyps, without polyps and when it is fungal (we will not be talking about this third type)

Question 32

Is CRS curable in the vast majority of patients?

Answer 32

No

Therapeutic goals of CRS therapy can include controlling mucosal inflammation, maintaining sinus drainage and ventilation, treatment of infecting bacteria if present, and reducing the amounts of times they have an acute on chronic bacterial sinusitis.

Question 33

What therapy is done for CRS with NPA and without NP?

Answer 33

So, in general (for both CRS with NP and without NP), therapy can include irrigating the nasal passages with saline solutions reduces postnasal drainage, removes secretions, and rinses away allergens and irritants. Irrigation is probably more effective than a nasal spray.

There has been some data on the use of surfactants to disrupt bacterial biofilms. This has included baby shampoo. Currently the evidence is unconvincing.15 Intranasal corticosteroids (INC) appear to be useful in CRS with NP in that they there seems to be improvement for all symptoms, a moderate-sized benefit for nasal blockage and a small benefit for rhinorrhea.16 For patients with persistent nasal congestion or blockage despite consistent use of INC, changing to nasal corticosteroid instillations may provide some benefit.14 There is also some benefit in those with CRS but without NPs

Question 34

When can oral corticosteroids be used in CRS?

Answer 34

Oral corticosteroids may be provided to patients with CRS for to relieve severe and refractory mucosal edema in CRS without NP, and to possibly reduce the size of polyps in patients with CRS

Question 35

What is the controversy with using antibiotics in CRS?

Answer 35

It would appear that antibiotics do not provide a sustained effect

Some clinicians may use antibiotic therapy for CRS for an acute flare, while others when infection is possible and cannot be excluded, such as CRS without NP that is non-responsive to several months of topical glucocorticoids.18 For flares you may see durations of therapy of 7-21 days or when infection cannot be ruled out, up to 4 weeks.

Question 36

When might antileukotrien agents (Montelukast be used)

Answer 36

Antileukotriene agents such as montelukast may be used as add on therapy to INC in patients with CRS who also have allergic rhinitis or in patients with NP

Question 37

What is the cornerstone of therapy for CRS withOUT Nasal polyps?

Answer 37

SALINE IRRIGATION!

If relief is not provided, then be prepared to see pretty much anything. In those with NP and no significant nasal blockage, saline irrigation and INC are tried first. A “medical polypectomy” may be tried wherein brief course of oral corticosteroids (10-15 days) may be given the patient is very uncomfortable with nasal blockage, impaired sense of smell, or cannot use topical therapies due to polyps causing complete obstruction. Antibiotics for patients with CRS with NP are not recommended unless an infection is suspected. In the future, you may start to see biologics used for CRS with NP.