Case Studies (April 2019)
SJ, a 37-year-old man, comes to your hospital’s medicine clinic complaining of purulent drainage accompanied by nasal obstruction and facial pain that has persisted for the past 2 weeks. On questioning, SJ reports the purulent drainage is yellowish-green. The clinic’s advanced practice registered nurse (APRN) gives him a diagnosis of acute bacterial rhinosinusitis (ABRS). Clinic records show SJ has not adhered to follow-up appointments in the past. The nurse asks the pharmacist for his opinion regarding antibiotic therapy for SJ’s ABRS. As a pharmacist, how would you respond?
CASE 1 Answer: The 2015 guidelines from the American Academy of Otolaryngology recommend that clinicians either offer watchful waiting (ie, deferment of antibiotics for up to 1 week) or prescribe initial antibiotic therapy for patients with uncomplicated ABRS. Watchful waiting, however, should only be offered if the clinician is confident that follow up for reevaluation is likely if the illness persists or worsens. Because SJ is frequently nonadherent to follow-up, he is not a good candidate for watchful waiting. The pharmacist should recommend that SJ receive appropriate antibiotic therapy to treat his ABRS.
After concluding that SJ (the patient from Case 1) is not a candidate for watchful waiting, his APRN decides to start him on an antibiotic to treat his ABRS. Looking into SJ’s chart, you notice that he has no notable medical history, no known drug allergies, and takes no prescription or regular OTC medications. SJ currently works at a daycare and reports smoking 1 pack of cigarettes per day for the past 10 years. Which antibiotic should you recommend for initial therapy in this patient?
CASE 2 Answer: The American Academy of Otolaryngology recommends amoxicillin with or without clavulanate for 5 to 10 days as first-line treatment for adults with ABRS. For most patients with ABRS, amoxicillin is a reasonable first-line therapy due to its safety, efficacy, low cost, and narrow spectrum of activity. Amoxicillin-clavulanate is preferred for treating adults when there is a high risk for infection by an organism resistant to amoxicillin, such as penicillin nonsusceptible Streptococcus pneumoniae. Known risk factors for infection with an amoxicillin-resistant organism include antibiotic use in the past month, close contact with antibiotic-treated individuals, being a health care provider or working in a health care environment, close contact with a child who attends daycare, working at a daycare facility, being a smoker or having one in the family, and living in an area with a high prevalence of resistant bacteria Because SJ works at a daycare facility and is a smoker, he is at high risk for resistant bacteria causing his ABRS. Therefore, amoxicillin-clavulanate 2000/125 mg administered orally twice daily for 5 to 10 days would be the most appropriate choice for him.
Kyulim Lee is a PharmD candidate at the University of Connecticut School of Pharmacy, Storrs, Connecticut.Erin R. Weeda, PharmD, is an outcomes research fellow at the University of Connecticut School of Pharmacy.Craig I. Coleman, PharmD, is professor of pharmacy practice at the University of Connecticut School of Pharmacy.