Recent estimates suggest that the direct annual costs of sinusitis are approximately $5.8 billion in the United States, and nearly one in seven Americans is diagnosed with a sinus infection every year. Rhinosinusitis is one of the most common reasons patients seek medical help. It ranks among the top five reasons for antibiotic prescriptions for adults. However, 90% to 98% of patients presenting with symptoms of sinusitis have viral causes and will not benefit from antibiotics. The overuse of antibiotics among this population has contributed largely to the emergence of antimicrobial resistance.

The Need for Guidance

“Clinicians need clear guidance on how to treat patients with rhinosinusitis and on how to differentiate viral from bacterial infections,” says Thomas M. File, Jr., MD. In the April 15, 2012 issue of Clinical Infectious Diseases, Dr. File coauthored guidelines from the Infectious Disease Society of America (IDSA) on acute bacterial rhinosinusitis in children and adults. “Reasonable criteria are needed for making decisions on when it’s appropriate to prescribe antibiotics in rhinosinusitis,” he says. “We also wanted to provide an update on the information available on the bacteria that are causing bacterial sinusitis as a result of emerging resistance [Table 1].”

With no simple test to quickly determine whether an infection is viral or bacterial, many physicians prescribe antibiotics to play it safe. According to Dr. File, this practice has led patients to expect to receive antibiotics when they have an infection. “If they aren’t prescribed one, they may be dissatisfied with the patient–physician interaction,” he adds. “Patients and physicians both need to be educated that using antibiotics when they’re unwarranted will provide no benefit and may actually be harmful. Such practices can lead to increased antibiotic resistance, exposure to drug side effects, and higher costs without resolution of their symptoms.”

When to Prescribe Antibiotics

The guidelines explore the management of three scenarios in which patients are likely to have sinusitis of bacterial origin and benefit from antibiotics:

1. Symptoms of sinusitis (Table 2) lasting for more than 10 days without improving.

2. Severe symptoms of sinusitis associated with fever of 102º or higher, nasal discharge, and facial pain for 3 to 4 days.

3. Symptoms of viral sinusitis that continue to gradually worsen over 5 or 6 days and are accompanied by new fever, headache, or increased nasal discharge, typically following a viral upper respiratory infection of 5 or 6 days.

On http://www.physweekly.com, the IDSA’s algorithm on managing acute bacterial rhinosinusitis will be provided beginning in January 2013. It provides clinicians with detailed information on how to proceed with managing patients in any of these clinical scenarios.

Treatment Recommendations

Prior guidelines for sinusitis from other organizations recommend using amoxicillin as first-line therapy for bacterial infections. “Over the past 5 years or so, some pathogens have shown resistance to amoxicillin,” explains Dr. File. “The IDSA now recommends amoxicillin-clavulanate because clavulanate enhances the activity of amoxicillin against these resistant pathogens.” Whereas previous guidelines recommend that treatment last from 7 to 10 days—or even 21 days in some cases—the IDSA guidelines recommend treatment of 5 to 7 days for adults and 10 to 14 days for children. “Reducing the duration of treatment also reduces related events and costs,” adds Dr. File. “Research shows that it does not jeopardize response.”

The IDSA guidelines note that nasal saline irrigation may help with drainage and allow healing of the mucosa of the sinuses. Over-the-counter decongestants are advised against for both bacterial and viral infections. “Decongestants have not been shown to be helpful,” Dr. File says. “Animal studies actually suggest that they prolong the inflammatory state of the mucosa.”

Increasing Appropriate Antibiotic Use

Dr. File stresses the importance of avoiding overuse of antibiotics for rhinosinusitis. “In some scenarios, it won’t be clear whether a patient has rhinosinusitis of bacterial or viral infection,” he says. “If physicians follow the new IDSA guideline recommendations, they can be more confident if the infection is bacterial based on clinical manifestations. As a result, the likelihood of using antibiotics appropriately will increase.”

References

Chow A, Benninger M, Brook I, et al. Executive summary:IDSA clinical practice guideline for actue bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54:1041-1045. Available at http://cid.oxfordjournals.org/content/54/8/1041.

Meltzer E, Hamilos D, Hadley J, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol. 2004;114:155-212.

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;371:908-914.

Rosenfeld R, Singer M, Jones S. Systematic review of antimicrobial therapy in patients with acute rhinosinusitis. Otolaryngol Head Neck Surg. 2007;137:S32-S45.

Falagas M, Giannopoulou K, Vardakas K, et al. Comparison of antibiotics with placebo for treatment of acute sinusitis: a meta-analysis of randomised controlled trials. Lancet Infect Dis. 2008;8:543-552.

Hadley J, Mosges R, Desrosiers M, et al. Moxifloxacin five-day therapy versus placebo in acute bacterial rhinosinusitis. Laryngoscope. 2010;120:1057-1062.

Williamson I, Rumsby K, Benge S, et al. Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: a randomized controlled trial. JAMA. 2007;298:2487-2496.

Wald E, Nash D, Eickhoff J. Effectiveness of amoxicillin/clavulanate potassium in the treatment of acute bacterial sinusitis in children. Pediatrics. 2009;124:9-15.