Diagnosing and Treating Rhinosinusitis: New Guidelines: Bacterial vs Viral Rhinosinusitis
Anthony W. Chow, MD
Bacterial vs Viral Rhinosinusitis
Although rhinosinusitis is quite common -- affecting nearly 1 in 7 adults each year -- the prevalence of bacterial infection during acute rhinosinusitis is estimated to be only 2%-10% of all patients with symptoms of sinusitis.[2,3] Antibiotics are significantly overprescribed for rhinosinusitis, which is the fifth leading indication for antimicrobial prescriptions by physicians in office practice.One national survey conducted during 1998-2003 revealed that 81% of adults presenting with symptoms of sinusitis in an outpatient setting received an antibiotic prescription. Overprescription of antibiotics is a serious concern because it is costly, exposes patients to unnecessary side effects, and fosters drug resistance.
Due to the lack of precision and practicality of current diagnostic methods, clinicians must rely on clinical presentations to distinguish bacterial from viral rhinosinusitis. The guidelines suggest that the infection is probably bacterial if any of the following are true:
- Onset with persistent symptoms or signs compatible with acute rhinosinusitis lasting for ≥ 10 days without any evidence of clinical improvement;
- Onset with severe symptoms or signs of high fever (≥ 39°C or 102°F) and purulent nasal discharge or facial pain lasting for at least 3-4 consecutive days at the beginning of an illness; or
- Onset with worsening symptoms or signs characterized by new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection that lasted 5-6 days and initially improved ("double-sickening”).
Once a bacterial cause is established based on these clinical presentations, empiric antimicrobial therapy should be initiated immediately with amoxicillin-clavulanate, which has better coverage than amoxicillin. This recommendation is a result of the following:
- Increasing prevalence of Haemophilus influenzae among other respiratory tract infections in children since the introduction of the pneumococcal vaccines; and
- High prevalence of beta-lactamase-producing respiratory pathogens in ABRS among recent respiratory tract isolates, particularly H influenzae.
- Doxycycline may be used as an alternate regimen in adults;
- The following are not recommended because of resistance issues: macrolides, such as clarithromycin and azithromycin; trimethoprim-sulfamethoxazole; and second- and third-generation oral cephalosporins;
- Combination therapy with a third-generation oral cephalosporin plus clindamycin may be used in children with non-type-1 penicillin allergy or who are from geographic regions with high endemic rates of penicillin-nonsusceptible S pneumoniae. Levofloxacin is recommended for children with type-1 penicillin allergy; and
- Respiratory fluoroquinolones may be used in patients in whom first-line therapy failed or who have risk factors for antibiotic resistance.
Length of therapy:
- Adults: 5-7 days for uncomplicated ABRS
- Children: 10-14 days
- Intranasal saline irrigations with physiologic or hypertonic saline may be helpful in adults but are less likely to be tolerated in children;
- Intranasal corticosteroids are recommended in persons with a history of allergic rhinitis; and
- Topical and oral decongestants and antihistamines are not recommended.