Teeters, Jennifer ATC; Boles, Michelle; Ethier, Julie; Jenkins, Ambria; Curtis, L. Gail PA-C, MPAS
Jennifer Teeters, Michelle Boles, Julie Ethier, and Ambria Jenkins are graduates of the PA program at Wake Forest School of Medicine, Winston-Salem, North Carolina. L. Gail Curtis is an associate professor and vice chair of the department of physician assistant studies at Wake Forest School of Medicine. The authors have indicated no relationships to disclose relating to the content of this article.
Roy A. Borchardt, PA-C, PhD, department editor.
ABSTRACT: New treatment guidelines for acute rhinosinusitis outline when antibiotic therapy is appropriate, as well as describe evidence-based treatment to relieve symptoms, prevent complications, and prevent chronic disease.
Acute rhinosinusitis continues to be one of the most common conditions treated by primary care providers. In adults 18 years or older, almost 13% were given a diagnosis of rhinosinusitis within 12 months.1 More than one in five antibiotics prescribed in adults are for acute rhinosinusitis.2 This condition can have many causes, from allergens and environmental irritants to bacteria, fungi, and viral infection, with the latter being the most common cause of acute rhinosinusitis.3 Most cases are preceded by a viral upper respiratory infection (URI). The prevalence in young children is two to seven episodes per year and two to three episodes per year in adults.3–5 Viral causes account for 90% to 98% of cases; bacterial infection accounts for 2% to 10%.3 Secondary bacterial infection occurs in 0.5% to 2.0% of adult cases and about 5% of cases in children.2–5 Lack of sensitive and specific diagnostic testing means that clinicians must be able to accurately diagnose acute rhinosinusitis and, if bacterial infection is suspected, initiate appropriate antimicrobial therapy.
Acute rhinosinusitis is defined as inflammation of the lining of the nasal mucosa and paranasal sinuses. The paranasal sinuses include the paired maxillary, frontal, ethmoid, and the sphenoid sinuses. These sinuses are lined with ciliated epithelium that contain mucus-producing goblet cells.6 A viral infection causes inflammation of this epithelium and increased mucus production, which results in impaired mucociliary clearance.6 The cessation of mucus clearance causes obstruction of the sinuses, making it a suitable environment for the growth of bacteria. This entire process typically takes 7 to 10 days.
CLINICAL PRESENTATION AND DIAGNOSIS
The healthcare provider should know not only the signs and symptoms of acute rhinosinusitis but also how to distinguish a viral from a bacterial cause. According to 2012 guidelines from the Infectious Diseases Society of America (IDSA), clinical presentation criteria include duration of symptoms, typical clinical course, nasal discharge quality and additional symptoms.3 Typical clinical course of a viral infection includes symptoms of nasal discharge, congestion with cough, and often a sore throat.3 The nasal discharge is most often clear at first and becomes thicker and purulent after a few days. A distinguishing sign of an uncomplicated viral URI is the return of the nasal discharge to a clear watery consistency without the use of antimicrobial therapy. Additional symptoms characteristic of a viral URI include headaches and myalgias. Patients may also develop fever early in the illness.3 Respiratory symptoms of an uncomplicated viral URI will usually last between 5 and 10 days.3
One way to distinguish an uncomplicated viral upper respiratory infection from acute bacterial rhinosinusitis is by noting the typical clinical pattern of acute bacterial rhinosinusitis3:
* persistent symptoms lasting more than 10 days with no evidence of improvement
* onset with severe symptoms, including fever of 39° C (102° F) or higher or purulent nasal discharge at onset
* a “double-sickening” pattern, which includes new-onset fever, headache or increase in rhinorrhea that worsen or return after a 5- to 6-day viral presentation which was initially improving.
The “classic” presentation of acute bacterial rhinosinusitis in adults is characterized by a triad of symptoms including headache, facial pain, and fever. The most commonly reported symptoms include nasal congestion, purulent rhinorrhea, and facial pain or pressure.5 In children, the most common symptoms include cough with nasal discharge, fever, and malodorous breath.3
The diagnosis of acute rhinosinusitis is primarily based on clinical presentation. The conventional criteria for the clinical diagnosis of acute bacterial rhinosinusitis involves the presence of at least two major symptoms (such as purulent discharge and facial pain) or one major and two minor symptoms (such as headache and dental pain); for details, see the 2012 IDSA guidelines.3 The most accurate diagnostic approach is acquiring a quality history of disease pattern and progression and performing an appropriate physical examination.3
TREATMENT FOR RHINOSINUSITIS
The clinical picture will dictate the course of treatment. The primary objectives for acute viral rhinosinusitis are to relieve symptoms of nasal obstruction and rhinorrhea; treatment for acute bacterial rhinosinusitis includes antibiotics to eradicate the infection, prevent complications, and prevent chronic disease.6
Nonpharmacologic therapy Most healthcare providers will recommend nonpharmacologic treatments such as increased fluid intake, rest, and good personal hygiene. Water is the recommended fluid for avoiding dehydration and keeping mucous membranes moist, with increased intake requirements for illness. An adequate amount of rest provides time to fight off infection and is important for a prompt recovery. Proper hand washing techniques reduce the spread of virus and bacteria that cause rhinosinusitis and other illnesses.7
Ancillary therapy Common ancillary therapies include saline nasal spray, mucolytic agents, antipyretics/analgesics, decongestants, and antihistamines, but not all are favored by the IDSA guidelines. Saline spray can be used to irrigate the nasal cavity to soften secretions and improve mucociliary clearance.8 The IDSA guidelines recommend the use of nasal saline spray as an adjunctive treatment for rhinosinusitis in adults with low to moderate symptoms.3 The most common mucolytic agent is guaifenesin, which is used to thin mucus secretions and improve drainage.6 No clinical trials validate the use of guaifenesin, so the IDSA guidelines do not recommend it as adjunctive therapy for acute rhinosinusitis.3 Analgesics are used to relieve pain, and help patients to rest. Acetaminophen or an NSAID may be used for mild to moderate pain.8 Acetaminophen is also an effective antipyretic. Oral or topical decongestants and/or antihistamines are not recommended as adjunctive treatment in patients with acute bacterial rhinosinusitis because of their adverse effects in adults and children.3 Topical decongestants may induce inflammation and rebound congestion.6 Oral antihistamines may cause drowsiness and xerostomia.6 The FDA recommends that these drugs, found in OTC products, not be given to children younger than 2 years because of their potentially serious adverse reactions.3
Antibacterial therapy According to the IDSA guidelines, antibacterial therapy should be initiated as soon as the diagnosis of acute bacterial rhinosinusitis has been established. The recommended first-line drug for both children and adults is amoxicillin-clavulanate.3 Acute bacterial rhinosinusitis caused by Haemophilus influenzae and Moraxella catarrhalis has increased in children; and amoxicillin-clavulanate offers greater coverage of ampicillin-resistant strains of these bacteria. Doxycycline may be used as an alternative for empiric therapy for patients who cannot tolerate amoxicillin-clavulanate. In patients with a penicillin allergy, the recommendations include doxycycline or a respiratory fluoroquinolone such as levofloxacin or moxifloxacin. Because of high rates of resistance among Streptococcus pneumoniae, macrolides, trimethoprim-sulfamethoxazole, or third-generation cephalosporins are not recommended for empiric therapy. The IDSA guidelines list potential causative agents for acute bacterial rhinosinusitis in Table 6; first-line and second-line antimicrobial therapies are listed in Table 10.3 Treatment duration recommendations include 5 to 7 days for adults and 10 to 14 days for children, based on symptomatic improvement. Figure 1 in the IDSA guidelines is an algorithm for management.
Clinicians must treat acute bacterial rhinosinusitis with the appropriate antimicrobial therapy and understand how to manage patients who fail to respond to this therapy. Consider an alternate plan if the patient's symptoms worsen after a 2- to 3-day trial of antibiotics or if there is no response after 3 to 5 days. The antimicrobial agent needs to be reevaluated and consideration must be given to noninfectious causes. Further workup should be initiated, such as endoscopic evaluation of the sinuses with direct sinus aspiration for culture.
Acute bacterial rhinosinusitis is a common complication of acute viral rhinosinusitis, so differentiating between viral and bacterial causes is imperative to determining proper management. The IDSA's minor and major clinical symptoms serve as strong indicators to assist clinicians with diagnosis. When the clinical picture suggests a bacterial cause, current evidence-based recommendations are for use of amoxicillin-clavulanate as first-line empiric treatment. Healthcare providers should familiarize themselves with the 2012 IDSA guidelines and use appropriate prescribing criteria to prevent antimicrobial resistance and further complications.
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© 2013 American Academy of Physician Assistants.