Rhinosinusitis - Acute, Bacterial Management

Evaluation of disease severity of acute bacterial rhinosinusitis will be dependent on clinical judgment. The visual analogue scale (VAS) score may also be used to evaluate disease severity: Mild if VAS 0-3 cm; moderate if VAS >3-7 cm; and severe if VAS >7-10 cm.

Symptoms of life-threatening illnesses (high, persistent fever >38.9°C [>102°F], periorbital edema, inflammation, or erythema, cranial nerve palsies, abnormal extraocular movements, proptosis, vision changes [double vision or impaired vision], severe headache, altered mental status, signs of sepsis, or meningitis) should warrant referral to the emergency department or an otorhinolaryngologist. The severity assessment will also guide the analgesic therapy. Differences in severity do not necessarily imply antimicrobial resistance.

Recent Antibiotic Use

Recent antibiotic use (within the last 4–6 weeks) is a major factor that is associated with an increased risk of resistant pathogens.

OTORHINOLARYNGOLOGIST REFERRAL

Referral to an otorhinolaryngologist should be done if there is no improvement from first- or second-line agents, especially in severely ill or immunocompromised patients with uncontrolled diabetes, end-stage renal failure, and human immunodeficiency virus. Other indications for otorhinolaryngologist referral include: Recurrent bacterial rhinosinusitis (≥4 episodes/year); granulomatous disease or fungal sinusitis; development of complications; chronic rhinosinusitis with frequent ABRS exacerbations; unusual opportunistic or resistant organisms; anatomical anomalies that cause obstruction; failure to respond to extended antibiotic courses; presence of comorbidities; hospital-acquired infection; suspected malignancy; and the need for special procedures (eg CT scan, maxillary sinus tap [MST] for sinus puncture and aspiration, endoscopically directed middle meatal culture [EDMMC]).

Emergency specialist referral is needed if any of the following is present: Periorbital cellulitis or preseptal edema; displacement of orbital globe; double vision; eye pain or ophthalmoplegia; reduced visual acuity; severe unilateral or bilateral frontal headache; frontal sinus swelling; meningeal or focal neurologic signs (eg high fever, signs of meningeal irritation, altered mental status); signs of cavernous sinus thrombosis (eg bilateral lid drop, ophthalmic nerve neuralgia, retro-ocular headache, complete ophthalmoplegia, papilledema, prostration); and signs of sepsis. 

General Antibiotic Therapy Principles

Empiric therapy should be based on cost, safety, likely pathogen, local resistance patterns, and recent antibiotic use. Antibiotic therapy should be started in patients with the following presentations: Moderate-severe acute bacterial rhinosinusitis (ABRS) are patients with >3 consecutive days of fever (≥39°C) with purulent nasal discharge or facial pain; worsening ABRS is characterized as the presence of increased nasal discharge, headache, or new fever after a typical viral URTI of 5-6 days that was initially improving; persistent ABRS, if there are ≥10 days of symptoms (nasal discharge of any quality, cough) without signs of improvement; severe, worsening, or persistent ABRS with accompanying acute otitis media, pharyngitis, adenitis, or pneumonia, or if suspected to have orbital or intracranial involvement (alarm symptoms); and uncomplicated severe, worsening, or persistent ABRS without concomitant disease. In patients with uncomplicated acute bacterial rhinosinusitis with assurance for follow-up, the American Academy of Otolaryngology-Head and Neck Surgery recommend a "watchful waiting" period of 3-5 days after clinical diagnosis before initiating antibiotic therapy.

The initial antibiotic prescribed should be the most narrow-spectrum agent that is active against the likely pathogens, such as S pneumoniae, H influenzae, and M catarrhalis. Consider the local prevalence of resistance among each of the likely bacterial species. Initial empiric therapy coverage for S aureus or methicillin-resistant S aureus is not recommended. Factors that predispose patients to antibiotic-resistant bacteria need to be considered (eg antibiotic usage within the past month, hospitalization in the past 5 days, age <2 or >65 years, exposure to daycare, comorbid conditions, impaired immune response, severe infection, living in areas with high rates of resistance).

Goals of Antibiotic Therapy

The goals of antibiotic therapy in acute bacterial rhinosinusitis are to eradicate bacterial infection from the sinuses, hasten resolution of symptoms, prevent complications, and decrease the development of chronic disease. 

Symptomatic Therapy

Initial symptomatic management is the mainstay and most cost-effective treatment strategy for many patients. Most cases of acute rhinosinusitis, including acute viral rhinosinusitis (AVRS) and post-viral rhinosinusitis (PVRS), typically resolve without antibiotic therapy. Symptomatic therapy aims to relieve symptoms of nasal obstruction and rhinorrhea. A course of 7 days of watchful waiting may be sufficient if the patient presents with mild pain or temperature <38.3°C or 101°F and ensures follow-up. During the decision-making process, it is also important to consider the patient’s age, general health, cardiopulmonary status, and presence of comorbidities.

Analgesics and Antipyretics

Analgesics and antipyretics are useful in controlling pain as >50% of patients with acute bacterial rhinosinusitis report facial pain. Antipyretics may be used to relieve fever and pain.

Cough Preparations

Cough preparations may promote mucus drainage and clearance, but routine prescription is not recommended.

Corticosteroids

There is limited evidence to support use of oral corticosteroids in acute rhinosinusitis beyond pain relief. Intranasal corticosteroids may be used as an adjunct to empiric antibiotic therapy in patients with a history of allergic rhinitis. These provide symptomatic relief by decreasing mucosal inflammation, facilitating sinus drainage, and improving mucociliary clearance. Corticosteroids may be given as monotherapy for mild or moderate ARS and as an adjunct to antibiotics for severe cases. These may be prescribed in adults with PVRS when symptom reduction is necessary. There are minimal adverse effects with short-term use of nasal corticosteroids.

Decongestants

Decongestants increase the ostial diameter by reducing turbinate swelling and mucosal edema and may promote sinus drainage. Oral and intranasal decongestants may be beneficial in acute bacterial rhinosinusitis. Overuse of intranasal decongestants, or use for periods longer than 3–7 days, is not recommended due to the risk of rebound vasodilation. Based on clinical experience, intranasal decongestants are more effective and penetrate rapidly than oral decongestants.

Antihistamines

Antihistamines are not routinely prescribed unless there is concomitant allergic rhinitis.

Saline Irrigation

Saline irrigation has been shown to reduce symptoms and medication use when used alone or as an adjunct. This facilitates the removal of infective agents, mucus, and inflammatory mediators, decreases crusting in the nasal cavity, and increases mucociliary clearance. The use of sterile water or distilled saline as an irrigant is recommended due to reports of amoebic encephalitis arising from the use of contaminated water, and the use of table salt should also be avoided as it contains additives.

Mild Disease and No Antibiotics within the Last 4-6 Weeks

These therapies are suggested in patients who have not responded to symptomatic therapy or those whose symptoms have worsened.

Amoxicillin 







Amoxicillin continues to be the agent of choice for acute bacterial rhinosinusitis due to its safety, efficacy, low cost and narrow microbiologic spectrum when it is still effective in the locality. This is generally considered the most active of all oral beta-lactams against streptococci and only S pneumoniae that is highly resistant to Penicillin will not respond to conventional doses of Amoxicillin. The activity against beta-lactamase-negative strains of H influenzae is fair to good, but it is ineffective against beta-lactamase-producing strains.

Amoxicillin/Clavulanic Acid

Amoxicillin/clavulanic acid is recommended as initial empiric therapy for acute bacterial rhinosinusitis rather than Amoxicillin alone when bacterial resistance is likely (eg antibiotic use within the past month, close contact with previously treated individuals, healthcare professionals or environment, failure of prior antibiotic therapy, breakthrough infection despite prophylaxis, close contact with a child in a daycare facility, smoker or smoker in the family, and high prevalence or suspicion of resistant bacteria [beta-lactamase-producing strains of H influenzae, M catarrhalis]), presence of moderate to severe infection, protracted symptoms of acute bacterial rhinosinusitis, frontal or sphenoidal sinusitis, history of recurrent acute bacterial rhinosinusitis and presence of comorbidities.

High-dose Amoxicillin with Clavulanic acid (2 g/125 mg PO twice a day) should be considered in patients at high risk of being infected with Penicillin non-susceptible S pneumoniae, those with severe infection (eg evidence of systemic toxicity with temperature of ≥39°C, with threat of suppurative complications), patients aged over 65 years who have had a recent hospitalization, used antibiotics within the past month, or are immunocompromised.

Cephalosporins (Second and Third Generation) 







Example drugs: Cefaclor, Cefdinir, Cefixime, Cefuroxime, Cefpodoxime, Ceftriaxone

Cephalosporins are alternative agents that may be considered for patients with acute bacterial rhinosinusitis who have a non-type 1 allergy to Penicillin. Because of variable resistance to S pneumoniae, single-agent empiric therapy is not recommended.  Local resistance patterns and the antimicrobial spectrum of cephalosporins to S pneumoniae, H influenzae and M catarrhalis will need to be considered prior to choosing an agent. Cefaclor has poor overall efficacy against bacterial respiratory tract pathogens. Cefixime has potent activity against H influenzae. Cefpodoxime is the preferred agent for patients with treatment failure on high-dose Amoxicillin or Amoxicillin/clavulanic acid. This has similar activity to Cefuroxime and Cefdinir against S pneumoniae but greater efficacy against H influenzae. Cefuroxime has good efficacy against S pneumoniae but is less active than Cefpodoxime against H influenzae. Intravenous or intramuscular Ceftriaxone (50 mg/kg single dose) may be considered for patients intolerant to oral medications and highly unlikely to adhere to prescribed medications.

Co-trimoxazole

Depending on the sensitivity pattern of local isolates, Co-trimoxazole may be considered an alternative for patients with type 1 allergy to Penicillin. This option is not advisable for empiric therapy due to increased rates of resistance to both S pneumoniae and H influenzae.

Doxycycline 







Doxycycline is an alternative agent to Amoxicillin or Amoxicillin/clavulanic acid in initial empiric therapy or to those who have type 1 allergy to Penicillin. Doxycycline has activity against Penicillin-susceptible pneumococci and M catarrhalis, but limited coverage for H influenzae. The probability of non-susceptibility to Doxycycline tends to rise in pneumococcal strains that have any level of Penicillin resistance.

Macrolides

Macrolides may be considered alternatives in patients who have type 1 allergy to Penicillin. These have good activity against macrolide-susceptible pneumococci but are not recommended for empiric therapy because of increasing prevalence of macrolide-resistant S pneumoniae. Azithromycin and Clarithromycin are relatively weak against penicillin-resistant H influenzae and S pneumoniae.

Moderate to Severe Disease or Antibiotics Received within the Last 4-6 Weeks

Patients who failed first-line therapy may be considered in this group of patients.

Amoxicillin/Clavulanic Acid

Amoxicillin/clavulanic acid is considered a first-line agent by many authorities for patients who have failed Amoxicillin or in those with risk for resistant organisms.

Please see Amoxicillin/Clavulanic Acid in the section on Mild Disease and No Antibiotics within the Last 4-6 Weeks for further information.

Ceftriaxone

A 5-day therapy of Ceftriaxone may be considered in those at risk for resistant organisms or in those who have failed first-line therapy.

Respiratory Quinolones

Example drugs: Levofloxacin, Moxifloxacin

Respiratory quinolones provide excellent coverage for all the likely pathogens, especially S pneumoniae and H influenzae. Because of the potential for increased resistance and toxicity, these agents should be reserved for adults with type 1 allergy to Penicillin and risk factors for resistant organisms, moderate disease, or those who have failed recent antibiotic coverage.

Combination Therapy

Example drugs: Cefixime + high-dose Amoxicillin or Clindamycin or Rifampicin + high-dose Amoxicillin or Clindamycin

Combination therapy with adequate Gram-positive and negative coverage may be considered in patients with risk of resistant organisms, moderate disease, or failed first-line therapy. There is no clinical evidence supporting the use or safety of combination therapy, but it is recommended based on in vitro spectrum activity. Rifampicin + Clindamycin may be an option for combination therapy. Rifampicin should not be used as monotherapy or for longer than 10-14 days because of the rapid development of resistance. Clindamycin/Linezolid + Cefixime is recommended for patients with severe type 1 Penicillin hypersensitivity with moderate to severe sinusitis.

The appropriate duration of antibiotic therapy is not well defined. Most patients with acute bacterial rhinosinusitis that have been treated with the appropriate antibiotic agent will show clinical improvement within 48-72 hours. If patient worsens or does not improve after 3-5 days of appropriate antibiotic therapy, reassess patient to confirm acute bacterial rhinosinusitis, rule out alternative diagnoses, and identify possible complications; if acute bacterial rhinosinusitis is confirmed, the antibiotic should be changed.

If acute bacterial rhinosinusitis is worse within 72 hours after initiating treatment, the following may be done: If initially advised further observation, may start Amoxicillin with or without Clavulanate therapy; if initially prescribed with Amoxicillin, may increase dose and add Clavulanate; and if initially prescribed with high-dose Amoxicillin-Clavulanate, may shift to Clindamycin + Cefixime or Linezolid + Cefixime or Levofloxacin.

If no clinical improvement seen after 72 hours, the following may be done: If initially advised further observation, may start antibiotic therapy; if initially prescribed with Amoxicillin, may initiate high-dose Amoxicillin/clavulanate therapy; and if initially prescribed with high-dose Amoxicillin-Clavulanate, may continue giving high-dose Amoxicillin-Clavulanate or may shift to Clindamycin + Cefixime or Linezolid + Cefixime or Levofloxacin.

In patients without severe ABRS and comorbidities, they may benefit from short-course treatment, which leads to better compliance, fewer adverse effects, lower resistance rates, and lower costs of medications. Short-course treatment with appropriate oral antibiotic treatment is given for 7 days and may be extended to 14 days if symptoms fail to resolve. The duration of antibiotic therapy in patients with moderate to severe ABRS is 7-14 days. 

Patient Education

Reassure and educate the patient about the nature of upper respiratory tract infection, acute viral rhinosinusitis, post-viral rhinosinusitis, acute bacterial rhinosinusitis, and expected duration of illness. Encourage the patient to implement home self-care measures to provide relief of symptoms and prevent the occurrence of acute bacterial rhinosinusitis. Maintain adequate hydration by drinking 6-10 glasses of water/day to thin the mucus. Inhaled steam (from a hot bath/shower) may loosen secretions. If necessary, increase humidity at home. Apply warm facial packs (eg warm washcloth, hot water bottle) for 5-10 minutes ≥3x/day to promote drainage of mucus and provide some localized relief.

Patients should have adequate rest. Avoid irritants that affect sinuses (eg cigarette smoke, extreme cool or dry air, pollution, swimming in contaminated water, and barotrauma). Appropriate management should be done for allergies and viral URTIs. Hygiene measures such as frequent handwashing to prevent spread of respiratory viruses. There is little evidence on the efficacy of phytomedical preparations, immunomodulators, and bacterial lysate preparations. There is no proven benefit to the use of mist, zinc salt lozenges, ascorbic acid, or echinacea.

Treatment with Antibiotics

Educate the patient about worsening signs and symptoms that should prompt them to contact a physician. It is important to counsel the patient on the use of the medications, their dosing schedule, and potential adverse effects. It is important to instruct the patient to complete the course of antibiotics.