QUEST Integration – Rhinosinusitis, Acute – Treatment for Adults

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Guideline summary

• Guideline applies to immunocompetent adults.
• Rhinosinusitis is frequently a viral infection
• Bacterial sinusitis is not common in patients whose symptoms last more than 7 days
• Symptoms of bacterial sinusitis include:
  • purulent nasal discharge along with maxillary tooth or facial pain (especially when unilateral)
  • unilateral sinus tenderness
  • worsening symptoms
• Clinical trials, amoxicillin, doxycycline or trimethoprim-sulfamethoxazole are favored antibiotics

Introduction

Sinusitis refers to inflammation of the mucosa of the paranasal sinuses. Because it is invariably accompanied by inflamed contiguous mucosa, sinusitis is more appropriately referred to as rhinosinusitis. Rhinosinusitis is one of the 10 most common diagnoses in ambulatory practice and the fifth most common diagnosis for which antibiotics are prescribed. Primary care physicians tend to treat this as an acute bacterial infection and prescribe an antibiotic more than 85 percent of the time. However, rhinosinusitis is frequently a viral infection, and even if bacterial in origin, often will resolve in most patients without antibiotic treatment.

Goals/desired outcomes

The goals of appropriate diagnosis and treatment of rhinosinusitis include:

• Use of antibiotics only when indicated, beginning with first-line antibiotics
• Appropriate use of imaging studies

The following recommendations apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease.

• Acute rhinosinusitis, whether bacterial or viral, usually does not require antibiotic treatment, especially if symptoms are mild or moderate.
• Treat patients with severe or persistent moderate symptoms and specific findings of bacterial rhinosinusitis with antibiotics.
• Sinus radiography is not recommended for the diagnosis of uncomplicated sinusitis. In the primary care setting, imaging studies (i.e., sinus CT or sinus X-ray series) have not been shown to be cost-effective and should not be routinely done in the initial assessment of sinusitis. However, when the clinical findings are unclear and empiric therapy fails, imaging studies (i.e., sinus CT or sinus X-ray series) may be used to clarify the diagnosis and to determine the length and type of antibiotics to be used.

Diagnosis

The symptoms of acute rhinosinusitis lack specific clinical features to distinguish it from nonbacterial upper respiratory tract infections. Rhinovirus illnesses are common and usually last from one to 33 days. Most patients will be well or nearly well in seven to 10 days. However, 25 percent will still be symptomatic after 14 days. Bacterial sinusitis is not common in patients whose symptoms have lasted less than seven days. Therefore, the presence of symptoms for at least seven days is a moderately sensitive but nonspecific predictor of bacterial rhinosinusitis. Purulent nasal discharge, maxillary tooth or facial pain (especially when unilateral), unilateral sinus tenderness and worsening of symptoms appear to predict bacterial infection.

Treatment

• Provide symptomatic treatment and reassurance (the preferred initial management strategy for patients with mild symptoms).
• Do not use sinus radiography for diagnosis in routine cases.
• Reserve antibiotic therapy for patients with severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis, regardless of duration of illness.
• Use first-line agents when providing initial antibiotic treatment. Clinical trials suggest that amoxicillin, doxycycline and trimethoprimsulfame-thoxazole are the preferred antibiotics.

Patient education and satisfaction

Many patients expect to receive a prescription as treatment for the “common cold” (viral infections). However, obtaining an antibiotic prescription is not always correlated with increased patient satisfaction. Hamm et al., reported patient satisfaction immediately after a visit was most highly related to patients’ reports of how much time the physician spent explaining the illness, and their understanding of the physician’s choice of treatment, and not to the physician’s prescribing antibiotics.

The physician may feel a duty to treat the patient presenting with a mild but uncomfortable illness with antibiotics, even if the likelihood of improving the outcome is small. Although antibiotics may offer little direct benefit, the physician may perceive even an insignificant clinical benefit as worth the economic cost to the patient. Potential adverse drug reactions, the association between antibiotic overuse, the development of resistant organisms and the expense of antibiotics are compelling reasons for prescribing them only when necessary.

When patients ask for antibiotics to treat a viral upper respiratory infection (VURI), discussions may include the following:

• Antibiotics are appropriately prescribed for bacterial infections, not viral infections. Treating viral infections with antibiotics is not effective and does not serve as a preventive measure against bacterial infection.
• Unnecessary antibiotics can be harmful (e.g., may cause adverse drug reactions).
• The latest evidence indicates that unnecessary antibiotics promote resistant organisms in the patient and the community.
• Build trust; do not minimize the illness as “only a viral infection”.
• Convey a sense of partnership. Develop a symptomatic treatment plan with the patient (or caregiver) describing the expected course of the illness over time with instructions to return if symptoms persist or worsen.
• Prescribe analgesics, decongestants and/or other symptom-based therapies, if appropriate. Emphasize the importance of adequate hydration and nutrition, and consider providing “care packages” containing nonantibiotic therapies.

Education strategies

• Patient satisfaction correlates with physician time explaining the illness, not receiving antibiotics
• Explain that treating viral infections with antibiotics is not effective
• Unnecessary antibiotics can be harmful
• Describe the expected course of the illness over time with instructions of what to do if symptoms persist or worsen

Treatment

• Provide symptomatic treatment and reassurance (the preferred initial management strategy for patients with mild symptoms).
• Do not use sinus radiography for diagnosis in routine cases.
• Reserve antibiotic therapy for patients with severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis, regardless of duration of illness.
• Use first-line agents when providing initial antibiotic treatment. Clinical trials suggest that amoxicillin, doxycycline and trimethoprim sulfamethoxazole are the preferred antibiotics.

Rhinosinusitis Treatment Algorithm [PDF]

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Sources

1. Snow V. et al Principles of Antibiotic Use for Acute Sinusitis in Adults. Annals of Internal medicine 2001; 134:495-497.

References

1. Institute for Clinical Systems Improvement. (2002). Diagnosis and treatment of respiratory illness in children and adults. Copyright 2004, Institute for Clinical Systems Improvement. Used with permission.

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