Medical Minute: Evidence-Based Management of Acute Bacterial Rhinosinusitis (ABRS) in Children and Adults

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July 22, 2015 by dailybolusoflr

By: Casey Wilson, MD

IDSA Guidelines: COCHRANE Systematic Review, 1980 – 2011
  • Cost Analysis: Total direct healthcare costs attributed to bacterial sinusitis ~ $3 Billion
  • 81% of adults prescribed antibiotics for bacterial sinusitis, despite the fact that 70% will improve without intervention in placebo-controlled RCT’s

 Major Recommendations

o   Diagnosis of ABRS
  •  > 10 days without clinical improvement
  • Purulent nasal discharge, high fever (> 102 F), facial pain > 3-4 days
  • Viral URI that initially improves over 5-6 days followed by worsening symptoms, “double sickening” (strong recommendation, moderate quality evidence)

o   Initial Empiric Treatment

§  Augmentin (not Amoxicillin) should be initial treatment in children for 10-14 days (strong recommendation, moderate quality evidence) and adults for 5-7 days (weak recommendation, low quality evidence)
§  Consider high dose (2 g PO BID or 90 mg/kg/day) Augmentin if high rate of PCN-resistent Strep. Pneumo, systemic toxicity, 65, recent hospitalization, daycare attendance, immunocompromised (weak recommendation, moderate evidence)
§  Macrolides (Clarithromycin, Azithromycin) and Bactrim not recommended due to high rates of resistance (~30-40%) (strong recommendation, moderate evidence)
§  PCN allergy: Doxycycline is good alternative for adults, Levofloxacin or Clinda + Cefpodoxime is good alternative in children (strong recommendation, moderate evidence)
§  Do not cover for MRSA empirically
o   Refractory Sinusitis

§  If symptoms worsen 48-72 hours after or fail to improve 3-5 days after
§  Should be evaluated for resistant pathogens, structural abnormalities, etc.
§  Cultures should be obtained via direct sinus aspiration, rather than NP swab, but cultures are unreliable and not recommended for the diagnosis of sinusitis (strong recommendation, moderate evidence)
§  CT rather than MRI recommended for localization (weak recommendation, low evidence)
§  Refer to specialist (ENT, Allergist, Infectious Disease) IF immunocompromised, systemically ill, recurrence or extended courses of sinusitis despite antibiotics (good practice recommendation, not graded by evidence)
o   Topical or oral decongestants or antihistamines

§  Neither are recommended as adjunct treatment (strong recommendation, low-moderate evidence)
o   Intranasal corticosteroids

§  Recommended as adjunct treatment in patients with history of allergic rhinitis (weak recommendation, moderate evidence)
o   Nasal Saline Irrigation

§  Recommended as adjunct treatment in adults(weak recommendation, low-moderate quality evidence)
Chow, AW; et. Al. “IDSA clinical practice guidelines for acute bacterial rhinosinusitis in children and adults.” Clin Infect Dis. 2012 April; 54(8) e72-e112.
**It’s important to tailor antibiotic choice to your local community resistance patterns.  For example, Doxycycline is not included in the JHH antibiotic guide for ABRS management due to high levels of S. Pneumo (27%) and H. flu (35%) resistance.

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