September 2000
WASHINGTON, D.C. - Differentiating between viral respiratory infections and sinusitis can be difficult, often leading to inappropriate use of antibiotics.
"At least half of the patients who get antibiotics don't need them," said Michael R. Jacobs, MD, PhD, professor of pathology and medicine at Case Western Reserve University in Cleveland.
New guidelines, released by the Sinus and Allergy Health Partnership and published in Otolaryngology - Head and Neck Surgery, are expected to help health professionals diagnose acute bacterial rhinosinusitis more accurately, reduce the use of antibiotics for nonbacterial infections and choose the most effective treatment when acute bacterial rhinosinusitis is likely.
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Acute bacterial rhinosinusitis may develop as a complication of nasal allergies or a viral respiratory infection. Symptoms of a viral infection or allergies include sneezing, runny nose, nasal congestion, facial pressure, postnasal drip, sore throat and fever. The inflammation produced by these symptoms prevents the sinuses from draining normally, resulting in acute, but not necessarily bacterial rhinosinusitis.
In general, a diagnosis of acute bacterial rhinosinusitis should be made when cold symptoms do not improve after 10 days or worsen after five to seven days. Symptoms of acute bacterial infection include nasal drainage, nasal congestion, facial pressure or pain, postnasal drainage, hyposmia or anosmia, fever, cough, fatigue, maxillary dental pain and a feeling of pressure or fullness in the ears.
The guidelines did not recommend use of radiographs or computed tomography (CT) and magnetic resonance imaging scans for initial diagnosis.
When picking an antimicrobial agent, severity of the disease, rate of disease progression, recent antibiotic therapies and rates of resistance should be considered, according to the guidelines.
Patients were divided into several categories: those with mild or moderate disease, those with and without antibiotic therapy within the previous month and those without a clinical response after 72 hours of therapy. Patients were defined as having mild disease if they were otherwise healthy but had 10 days of persistent anterior and posterior rhinorrhea and fatigue. Patients were defined as having moderate disease if they had 10 days of nasal congestion and developed a low-grade fever and increasing unilateral maxillary or frontal tenderness that worsened with bending over.
The guidelines analyzed and ranked 17 antibiotics used to treat sinusitis according to their efficacy in eradicating the bacteria most often responsible.
Antibiotics were placed into categories of expected clinical efficacy. Categories were based on predicted efficacy rates in fighting the bacteria most often responsible for this condition and a comparison of these rates with the rate at which bacterial infections resolve without antibiotics.
Amoxicillin/clavulanate (Augment-in, SmithKline Beecham), amoxicillin (45 mg/kg/day to 90 mg/kg/day), cefpodoxime proxetil (Vantin, Pharmacia) or cefuroxime axetil (Ceftin, Glaxo Wellcome) may be used as initial therapy for children with mild disease who have not received antibiotics in the previous four to six weeks. If a child has a history of immediate type 1 hypersensitivity reaction to ß-lactams, azithromycin (Zithromax, Pfizer), clarithromycin (Biaxin, Abbott), erythromycin or trimethoprim-sulfamethoxazole (TMP-SMX) are options, although their effectiveness against the major pathogens of acute bacterial rhinosinusitis is limited. Bacterial failure of 20% to 25% is possible with these agents.
The guidelines recommend differentiating between immediate hypersensitivity reactions to b-lactams and other less dangerous adverse events. Children with immediate hypersensitivity to b-lactams may need desensitization, sinus cultures or other ancillary procedures. Children with other reactions may tolerate one ß-lactam but not another.
Children who have moderate disease or who have taken antibiotics in the previous four to six weeks should receive amoxicillin/clavulanate, amoxicillin (80 mg/kg/day to 90 mg/kg/day), cefpodoxime proxetil or cefuroxime axetil, according to the guidelines.
Children who are younger than 5 or who attend day care should probably be included in this category, Jacobs said. "You may want to consider in a child younger than 5 in day care, that having been exposed to antibiotics or being exposed to a peer group that has taken antibiotics has pretty much the same effect."
In cases of b-lactam allergy, azithromycin, clarithromycin, erythromycin or TMP-SMX are recommended. If Streptococcus pneumoniae is identified as a pathogen, clindamycin should be considered.
Amoxicillin/clavulanate or combination therapy (amoxicillin or clindamycin for gram-positive coverage, plus cefpodoxime proxetil for gram-negative coverage) should be used for children with moderate disease who have taken antibiotics in the previous four to six weeks.
Antibiotic failure should always be a consideration, but it should be weighed against the need for future treatment options.
"The higher you start in the efficacy ranking of an antibiotic, the better chance you have of the drug working, but the more limited your choices if you need another drug," Jacobs said. "It's a trade off."
For more information:
- Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg. 2000;123(1):2.
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