Diagnosing and Treating Rhinosinusitis: New Guidelines

The Infectious Diseases Society of America has published its first-ever recommendations for the diagnosis and management of acute bacterial rhinosinusitis (ABRS) infections.^[1] The guidelines used the new GRADE system (Grading of Recommendations Assessment, Development and Evaluation), which is designed to more clearly assess the quality of evidence and report the strength of recommendations. The ABRS guidelines were posted online March 21, 2012, and will appear in the April 15, 2012, issue of Clinical Infectious Diseases.

Because the infection causes inflammation of both the sinuses and the nasal cavity, the ABRS guidelines use the term "rhinosinusitis" instead of the more common "sinusitis." The purpose of the guidelines is to provide clarity and guidance to physicians and other primary care providers in diagnosing and treating the infection. The guidelines specifically address the following:

• The inability of existing clinical criteria to accurately differentiate bacterial from viral acute rhinosinusitis, leading to excessive and inappropriate antimicrobial therapy;
• Gaps in knowledge and quality evidence about empiric antimicrobial therapy for ABRS as a result of imprecise patient selection criteria;
• Changing prevalence and antimicrobial susceptibility profiles of bacterial isolates associated with ABRS; and
• The effect of conjugated vaccines for Streptococcus pneumoniae on the emergence of nonvaccine serotypes associated with ABRS.

Although rhinosinusitis is quite common -- affecting nearly 1 in 7 adults each year -- the prevalence of bacterial infection during acute rhinosinusitis is estimated to be only 2%-10% of all patients with symptoms of sinusitis.^[2,3] Antibiotics are significantly overprescribed for rhinosinusitis, which is the fifth leading indication for antimicrobial prescriptions by physicians in office practice.^[4]One national survey conducted during 1998-2003 revealed that 81% of adults presenting with symptoms of sinusitis in an outpatient setting received an antibiotic prescription.^[5] Overprescription of antibiotics is a serious concern because it is costly, exposes patients to unnecessary side effects, and fosters drug resistance.

Due to the lack of precision and practicality of current diagnostic methods, clinicians must rely on clinical presentations to distinguish bacterial from viral rhinosinusitis. The guidelines suggest that the infection is probably bacterial if any of the following are true:

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

Antibiotic Treatment for Rhinosinusitis

First-line therapy:

Once a bacterial cause is established based on these clinical presentations, empiric antimicrobial therapy should be initiated immediately with amoxicillin-clavulanate, which has better coverage than amoxicillin. This recommendation is a result of the following:

• Increasing prevalence of Haemophilus influenzae among other respiratory tract infections in children since the introduction of the pneumococcal vaccines; and
• High prevalence of beta-lactamase-producing respiratory pathogens in ABRS among recent respiratory tract isolates, particularly H influenzae.

Second-line therapy:

• Doxycycline may be used as an alternate regimen in adults;
• The following are not recommended because of resistance issues: macrolides, such as clarithromycin and azithromycin; trimethoprim-sulfamethoxazole; and second- and third-generation oral cephalosporins;
• Combination therapy with a third-generation oral cephalosporin plus clindamycin may be used in children with non-type-1 penicillin allergy or who are from geographic regions with high endemic rates of penicillin-nonsusceptible S pneumoniae. Levofloxacin is recommended for children with type-1 penicillin allergy; and
• Respiratory fluoroquinolones may be used in patients in whom first-line therapy failed or who have risk factors for antibiotic resistance.

Length of therapy:

• Adults: 5-7 days for uncomplicated ABRS
• Children: 10-14 days

Adjunct therapy:

• Intranasal saline irrigations with physiologic or hypertonic saline may be helpful in adults but are less likely to be tolerated in children;
• Intranasal corticosteroids are recommended in persons with a history of allergic rhinitis; and
• Topical and oral decongestants and antihistamines are not recommended.

References

1. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54:1041-1045.http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full Accessed March 21, 2012.
2. Pleis JR, Lucas JW, Ward BW. Summary health statistics for U.S. adults: National Health Interview Survey, 2008. Vital Health Stat. 10;2009:1-157.
3. Gwaltney JM Jr, Wiesinger BA, Patrie JT. Acute community-acquired bacterial sinusitis: the value of antimicrobial treatment and the natural history. Clin Infect Dis. 2004;38:227-233. Abstract
4. Anand VK. Epidemiology and economic impact of rhinosinusitis. Ann Otol Rhinol Laryngol Suppl. 2004;193:3-5.Abstract
5. Gill JM, Fleischut P, Haas S, Pellini B, Crawford A, Nash DB. Use of antibiotics for adult upper respiratory infections in outpatient settings: a national ambulatory network study. Fam Med. 2006;38:349-354. Abstract