May 01, 2024

REBEL Core Cast 121.0 – Acute Sinusitis

5 minutes

Take Home Points

Acute rhinosinusitis is a clinical diagnosis

The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics

Consider the use of antibiotics in select groups with severe disease or worsening symptoms after initial improvement.

REBEL Core Cast 121.0 – Acute Sinusitis

Click here for Direct Download of the Podcast.

Definition:

Acute rhinosinusitis (ARS) – Symptoms for less than four weeks

Subacute rhinosinusitis – Symptoms for 4 to 12 weeks

Chronic rhinosinusitis – Symptoms persisting greater than 12 weeks

Recurrent acute rhinosinusitis – Four or more episodes of ARS per year, with interim symptom resolution

Epidemiology: (Anon 2004)

20 million cases of sinusitis annually in the US, costing $3.5 billion/year

Source of 1 in 5 antibiotic prescriptions for adults

Presentation:

Sinusitis is most commonly diagnosed by clinical symptoms

Common symptoms

Purulent nasal discharge

Nasal congestion

Facial pain or pressure, especially over a sinus or unilaterally

Anosmia

Hyposmia

Fever

Cough

Fatigue

Maxillary pain

Ear pressure or fullness.

Classification of Sinusitis:

●Acute viral rhinosinusitis (AVRS)

ARS with viral etiology (i.e. rhinovirus, influenza, and parainfluenza)

Most common form of ARS

●Uncomplicated acute bacterial rhinosinusitis (ABRS)

ARS with a bacterial etiology without clinical evidence of extension outside the paranasal sinuses and nasal cavity

Bacterial superinfection: 0.5-2% of all ARS

●Complicated acute bacterial rhinosinusitis

ARS with bacterial etiology with clinical evidence of extension outside the paranasal sinuses and nasal cavity

Sinusitis: Viral vs. Bacterial:

Color change in sputum does not determine whether infection is viral or bacterial

Viral infections

Tend to begin resolution by 7-10 days

Rarely have associated fevers

If fever present, usually only in the first 48 hours.

Guidelines for diagnosing ABRS are

Presence of URI/cold symptoms that

Don’t improve after 10 days

Worsen after 5-7 days of improvement

Severe symptoms including high fever, purulent discharge or facial pain for 3-4 days

The Data Behind Antibiotic Use

Clinically diagnosed acute sinusitis

Multiple studies show the same cure rate at 7 days, but improved cure rate at 7-14 days for those who use antibiotics (Lemiengre 2012, Berg 1986, Gwaltney 1996)

Overall Treatment Effect NNT = 18

Overall Harm NNH = 8 (mostly GI side effects)

Radiographically-diagnosed acute sinusitis (Ahovuo-Saloranta 2008)

Endpoint: clinical cure at 7-15 days

NNT = 15

NNH = 8

IDSA Recommendations for Antibiotic Treatment (Chow 2012)

Patients that should be treated

Persistent symptoms w/o improvement (> 10 days)

Severe symptoms (> 3-4 days)

Worsening (“double-sickening”) (> 3-4 days)

Antimicrobials

1st Line

Amoxicillin 875 mg PO BID X 5-7 days

Doxycycline 100 mg PO BID X 5-7 days

2nd Line

Amoxicillin/Calvulanate 875/125 mg PO BID X 5-7 days

Levofloxacin 500 mg PO Q24 X 5 days

Bottom Line: Given the risk for adverse events associated with antibiotic use, the growing specter of resistance and the lack of significant differences in outcomes with antibiotic use, it is better to avoid antibiotics in most patients with ARS. Antibiotics should be considered in those with severe disease and in immunocompromised patients

Take Home Points

Acute rhinosinusitis is a clinical diagnosis

The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics

Consider the use of antibiotics in select groups with severe disease or worsening symptoms after initial improvement.

References

Anon JB et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004; 130(Suppl 1): 1-45. PMID: 14726904

Lemiengre MB et al. Antibiotics for Clinically Diagnosed Acute Rhinosinusitis in Adults. Cochrane Database Syst Rev 2012. PMID: 23076918

Berg O et al. Occurence of asymptomatic sinusitis in common cold and other acute ENT-infections. Rhinology 1986; 24(3): 223-5. PMID: 3775189

Gwaltney JM. Acute community-aquired sinusitis. Clin Infect Dis 1996; 23(6): 1209-23. PMID: 8953061

Ahovuo-Saloranta A et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev 2008. PMID: 18425861

Chow AW et al. IDSA Clinical practice guideline for acute bacterial rhino sinusitis in children and adults. Clin Infect Dis 2012; 54(8): e72-e112. PMID: 22438350

Read More

The NNT.com: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults

The NNT.com: Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)

The post REBEL Core Cast 121.0 – Acute Sinusitis appeared first on REBEL EM - Emergency Medicine Blog.

...more

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By Salim R. Rezaie, MD

4.8

160160 ratings

May 01, 2024

REBEL Core Cast 121.0 – Acute Sinusitis

5 minutes

Take Home Points

Acute rhinosinusitis is a clinical diagnosis

The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics

Consider the use of antibiotics in select groups with severe disease or worsening symptoms after initial improvement.

REBEL Core Cast 121.0 – Acute Sinusitis

Click here for Direct Download of the Podcast.

Definition:

Acute rhinosinusitis (ARS) – Symptoms for less than four weeks

Subacute rhinosinusitis – Symptoms for 4 to 12 weeks

Chronic rhinosinusitis – Symptoms persisting greater than 12 weeks

Recurrent acute rhinosinusitis – Four or more episodes of ARS per year, with interim symptom resolution

Epidemiology: (Anon 2004)

20 million cases of sinusitis annually in the US, costing $3.5 billion/year

Source of 1 in 5 antibiotic prescriptions for adults

Presentation:

Sinusitis is most commonly diagnosed by clinical symptoms

Common symptoms

Purulent nasal discharge

Nasal congestion

Facial pain or pressure, especially over a sinus or unilaterally

Anosmia

Hyposmia

Fever

Cough

Fatigue

Maxillary pain

Ear pressure or fullness.

Classification of Sinusitis:

●Acute viral rhinosinusitis (AVRS)

ARS with viral etiology (i.e. rhinovirus, influenza, and parainfluenza)

Most common form of ARS

●Uncomplicated acute bacterial rhinosinusitis (ABRS)

ARS with a bacterial etiology without clinical evidence of extension outside the paranasal sinuses and nasal cavity

Bacterial superinfection: 0.5-2% of all ARS

●Complicated acute bacterial rhinosinusitis

ARS with bacterial etiology with clinical evidence of extension outside the paranasal sinuses and nasal cavity

Sinusitis: Viral vs. Bacterial:

Color change in sputum does not determine whether infection is viral or bacterial

Viral infections

Tend to begin resolution by 7-10 days

Rarely have associated fevers

If fever present, usually only in the first 48 hours.

Guidelines for diagnosing ABRS are

Presence of URI/cold symptoms that

Don’t improve after 10 days

Worsen after 5-7 days of improvement

Severe symptoms including high fever, purulent discharge or facial pain for 3-4 days

The Data Behind Antibiotic Use

Clinically diagnosed acute sinusitis

Multiple studies show the same cure rate at 7 days, but improved cure rate at 7-14 days for those who use antibiotics (Lemiengre 2012, Berg 1986, Gwaltney 1996)

Overall Treatment Effect NNT = 18

Overall Harm NNH = 8 (mostly GI side effects)

Radiographically-diagnosed acute sinusitis (Ahovuo-Saloranta 2008)

Endpoint: clinical cure at 7-15 days

NNT = 15

NNH = 8

IDSA Recommendations for Antibiotic Treatment (Chow 2012)

Patients that should be treated

Persistent symptoms w/o improvement (> 10 days)

Severe symptoms (> 3-4 days)

Worsening (“double-sickening”) (> 3-4 days)

Antimicrobials

1st Line

Amoxicillin 875 mg PO BID X 5-7 days

Doxycycline 100 mg PO BID X 5-7 days

2nd Line

Amoxicillin/Calvulanate 875/125 mg PO BID X 5-7 days

Levofloxacin 500 mg PO Q24 X 5 days

Take Home Points

Acute rhinosinusitis is a clinical diagnosis

The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics

Consider the use of antibiotics in select groups with severe disease or worsening symptoms after initial improvement.

References

Anon JB et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004; 130(Suppl 1): 1-45. PMID: 14726904

Lemiengre MB et al. Antibiotics for Clinically Diagnosed Acute Rhinosinusitis in Adults. Cochrane Database Syst Rev 2012. PMID: 23076918

Berg O et al. Occurence of asymptomatic sinusitis in common cold and other acute ENT-infections. Rhinology 1986; 24(3): 223-5. PMID: 3775189

Gwaltney JM. Acute community-aquired sinusitis. Clin Infect Dis 1996; 23(6): 1209-23. PMID: 8953061

Ahovuo-Saloranta A et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev 2008. PMID: 18425861

Chow AW et al. IDSA Clinical practice guideline for acute bacterial rhino sinusitis in children and adults. Clin Infect Dis 2012; 54(8): e72-e112. PMID: 22438350

Read More

The NNT.com: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults

The NNT.com: Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)

The post REBEL Core Cast 121.0 – Acute Sinusitis appeared first on REBEL EM - Emergency Medicine Blog.

...more