/publications/issue/2009/2009-04/2009-04-10219

Acute Bacterial Rhinosinusitis: Knowing the Signs

Author: Jeffrey A. Kyle, PharmD, and Jennifer Cortes, PharmD Candidate


Dr. Kyle is an assistant professor of pharmacy practice at the McWhorter School of Pharmacy at Samford University, Birmingham, Alabama. Ms. Cortes is a 2009 PharmD Candidate at Palm Beach Atlantic University, Gregory School of Pharmacy, West Palm Beach, Florida.


Approximately 20 million cases of acute bacterial rhinosinusitis (ABRS) occur every year in the United States.1 According to National Ambulatory Medical Care Survey data, ABRS is the fifth most common reason physicians prescribe antibiotics.1 ABRS results in >1.5 million ambulatory care visits and an expenditure of $5.3 billion yearly in the cost of office visits, procedures, and antibiotics.2

ABRS usually follows a viral upper respiratory tract infection, which can be caused by human rhinovirus, respiratory syncytial virus, adenovirus, parainfluenza, and enterovirus.1 ABRS also can develop as a result of nose and paranasal sinus inflammation, which can be caused by dental infection, allergies, or trauma.

The most prevalent risk factor for ABRS is having a recent viral upper respiratory tract infection. Other risk factors include allergic or nonallergic rhinitis, anatomical abnormalities (eg, a deviated septum or hypertrophic middle turbinates), diving and swimming, exposure to cigarette smoke, cystic fibrosis, and asthma.3

Monitoring Symptoms

The most common signs and symptoms of ABRS tend to overlap with those of viral upper respiratory tract infections. These begin after an initial blockage of the maxillary sinus ostium, located beneath the middle turbinate. This blockage, along with mucus retention and bacteria accumulation, bring about such symptoms as nasal drainage and congestion; facial pain or pressure, especially when concentrated in 1 area of the sinuses; postnasal drip; hyposmia and, in some cases, anosmia; fever; cough; fatigue; and possible dental and ear pain.1

According to a position paper of the Centers for Disease Control and Prevention, the American Academy of Family Physicians, the American College of Physicians-American Society of Internal Medicine, and the Infectious Diseases Society of America, 4 signs and symptoms are the most beneficial in predicting ABRS4: purulent nasal discharge; maxillary tooth or facial pain, especially when it is unilateral; unilateral maxillary sinus tenderness; and worsening symptoms after an initial improvement.4

Diagnosing ABRS

Due to overlapping symptoms, it often can be hard to properly diagnose ABRS. Physical examination provides very little information. Computed axial tomography scans and magnetic resonance imaging can be helpful at times in the diagnosis, but are not necessary for ABRS.1 The ideal way to confirm a diagnosis of ABRS is to aspirate the fluid from the affected sinuses and perform a culture.2,4 In the diagnosis of ABRS, the culture of the purulent sinus mucus should reveal at least 105 organisms per mL.4 This method is invasive, time-consuming, and painful and therefore not routinely performed.5 In general, a diagnosis of ABRS is made in children and adults when signs and symptoms have not improved after 10 days or when the symptoms worsen over 5 to 7 days.1

The question of whether or not to treat ABRS is not easy to answer for a number of reasons. Roughly 97.8% to 99.5% of rhinosinusitis cases are due to a viral infection and therefore do not require treatment with an antibiotic. More often than not, however, antibiotics are still prescribed despite increasing antibiotic resistance.2,4

A recent meta-analysis in the Lancet analyzed patient data from 9 randomized trials. The patient population included 2500 intention-to-treat patients diagnosed with ABRS who were randomized to receive an antibiotic or placebo.6 The outcome of interest was the proportion of patients cured.6 The results revealed the calculated number needed to treat (NNT) was 15.6 In patients with a purulent discharge, the NNT dropped to 8, revealing that 8 patients need to be treated before 1 additional patient is cured with antibiotics.6 The authors concluded that their results further validated that patients presenting with rhinosinusitis should not receive an antibiotic, unless a diagnosis is confirmed by imaging or culture.6 Additionally, they emphasized their results are not evidence against prescribers wanting to wait and watch the symptoms before treating with an antibiotic.6

Treatment Options

Should treatment be warranted, antibiotic regimens are targeted to adult and pediatric patient populations and are dependent on severity of symptoms, b-lactam allergy status, and recent antibiotic use (Tables 1 and 2). In patients who are at high risk for drug-resistant Streptococcus pneumoniae (DRSP), high-dose amoxicillin/clavulanate should be used. Patients who are considered high risk for DRSP include those who recently have used antimicrobials (past 4-6 weeks), as well as those who are immunodeficient, have recurrent sinusitis, or are a day care worker or attendee.

Table 1


Table 2


Those patients who do not respond to their prescribed antibiotic within 72 hours and their symptoms are persistent or worsening should be reevaluated and an alternate agent be selected.1,7 Overall, the duration of treatment has not been well established. Most evidence-based medicine concludes that treatment duration should last anywhere from 10 to 14 days.7 Ancillary therapies that are sometimes suggested to patients who have ABRS may include oral decongestants, topical decongestants, antihistamines, and normal saline nasal spray. These ancillary therapies for ABRS lack sound evidence, however.7 Whereas some trials have shown an improvement in symptoms, no clinical trials have shown that ancillary therapy decreases the duration of the infection.7

The Importance of Counseling

Pharmacists have a duty to accurately counsel patients on ABRS and be aware that the majority of sinus infections are viral in nature, and therefore do not require antibiotic therapy. Patients should be counseled on the signs and symptoms, even if the watch-and-wait approach is used. Pharmacists are an important source of information for patients on the use of antibiotics in ABRS, while working closely with physicians.

References

  1. Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg. 2004;130(suppl 1):1-45.
  2. Brook I. Current issues in the management of acute bacterial sinusitis in children. Int J Pediatr Otorhinolaryngol. 2007;71(11):1653-1661.
  3. Ah-See KW, Evans AS. Sinusitis and its management. BMJ. 2007;334(7589):358-361.
  4. Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part I evaluation. Am Fam Physician. 2004;70(9):1685-1692.
  5. Wald ER, Bordley WC, Darrow DH, et al. Clinical practice guideline: management of sinusitis. Pediatrics. 2001;108(3):798-808.
  6. Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet. 2008;371(9616):908-914.
  7. Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part II treatment. Am Fam Physician. 2004;70(9):1697-1704.