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Acute Bacterial Rhinosinusitis: Physician Information Sheet (Adults)

Principles of appropriate antibiotic use for acute rhinosinusitis apply to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in otherwise healthy adults.

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Sinus inflammation is often viral and usually resolves without antibiotics.

Background

  • Respiratory viruses typically cause inflammation of the nasalmucosa and maxillary sinuses.
  • Most cases of acute rhinosinusitis are due to uncomplicated viral infections.

Diagnosis

  • Most rhinovirus colds last 7 to 11 days (J Clin Microbiol 1997; 35:2864; JAMA 1967; 202:158).
  • Bacterial rhinosinusitis may be present if symptoms have been present >7 days and there is localization to the maxillary sinus.

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Signs/Symptoms of Acute Maxillary Sinusitis

(BMJ 1995;311:233)

 

Present
(N=92)
Absent
(N=82)
Odds
Ratio
Fever 89% 79% 2.1
Unilateral maxillary pain 51% 38% 1.9
Maxillary toothache 66% 51% 1.9
Unilateral maxillary
sinus tenderness
49% 32% 2.5

  • Generalized facial pain or tenderness, postnasal drainage, headache, and cough do not increase the predictive value of maxillary sinus symptoms.
  • Patients may rarely present with severe symptoms of bacterial rhinosinusitis less than 7 days duration (acute focal sinusitis). Consider immediate referral to an otolaryngologist for evaluation and drainage.
  • Sinus radiography is not recommended for routine evaluation of acute, uncomplicated bacterial rhinosinusitis.
    • Opacification and air-fluid level have sensitivity of ~ 73% and specificity of 80% (J Clin Epidemiol 2000;53:852).
    • Mucosal abnormalities are common in patients with viral infections (J Allergy Clin Immunol 1998;102:403).

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Treatment

  • Most patients with acute bacterial rhinosinusitis improve without antibiotic treatment.
    • About 81% of antibiotic treated patients and 66% of controls are improved at 10-14 days (absolute benefit of 15%).
  • Patients with mild symptoms should not receive antibiotics, but symptomatic treatment may be helpful.
    • Topical and oral decongestants may reduce nasal symptoms.
    • Most randomized trials of symptomatic therapies have been inconclusive. Patients with moderate or severe symptoms may benefit from antibiotics. Use a narrow spectrum agent that covers S. pneumoniae and H. influenzae.
    • Amoxicillin remains an appropriate choice for uncomplicated infections.
    • Consider second line agent if no improvement or worsening after 72 hours.

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Tips to Reduce Antibiotic Use

  • Tell patients that antibiotic use increases the risk of an antibiotic resistant infection.
  • Identify and validate patient concerns.
  • Recommend specific symptomatic therapy.
  • Spend time answering questions and offer a contingency plan if symptoms worsen.
  • Provide patient education materials on antibiotic resistance.
  • REMEMBER: Effective communication is more important than an antibiotic for patient satisfaction.
  • See www.cdc.gov/drugresistance/community or contact your local health department for more information and patient education materials.

Key Reference

Cooper RJ et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Annals of Internal Medicine 2001;134(6):509-17

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