Page 28 - Christiana Care Focus November 2018

Pharmacy Services |
Sinus infections: To treat or not to treat?
Rachael DiMeo, Pharm.D., Jillian Laude, Pharm.D., BCPS, Alexis Smith, Pharm.D.
A diagnosis of acute rhinosinusitis (ARS) is made in America over 30 million times each year.1 In addition to lost work time and de- creased productivity, this condition results in direct medical costs of more than three billion dollars annually.1,2 As the fifth leading diagnosis resulting in antibiotic prescriptions, it is imperative
that ARS is identified correctly and treated appropriately.1 While patients often request antibiotics during their office visits, inappro- priate use of antibiotics leads to detrimental effects, including, but not limited to, severe adverse effects and antimicrobial resistance.
ARS occurs when the mucosal lining in the paranasal sinus and nasal cavity become inflamed.1,3 The inflamed nasal mucosa respond to infection by producing mucus and recruiting white blood cells to the affected area.4 This immune system process results in the symptoms commonly associated with ARS, including purulent nasal drainage, nasal obstruction, and facial pain. However, these symptoms alone do not warrant treatment with antibiotics. Antibiotics should only be prescribed when a patient’s clinical presentation leads the prescriber to suspect bacterial etiology over viral etiology.
Bacterial vs. Viral
Viruses are the most common cause of ARS. In fact, 9 out of 10 cases in adults and 5-7 out of 10 cases in children are caused
by viruses. While bacterial and viral rhinosinusitis initially present in a similar fashion, key differences have been identified to distinguish one etiology from another (see Table 1). Bacterial rhinosinusitis is the more severe of the two and can last at least
10 days or more. The most common bacterial pathogens known
to cause ARS include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.3 Conversely, the natural course of symptoms with viral ARS typically presents for less than 10 days, and the associated symptom severity decreases overtime.
Treatment
Both bacterial and viral ARS are initially managed with adjunctive therapy intended to target patient specific symptoms. Analgesics or antipyretics manage pain and fever, oral decongestants help relieve nasal congestion, expectorants loosen and remove phlegm, and oral antihistamines may be used for relief of excessive secretions and sneezing.5 After initial symptom management, prescribers should employ a “watchful waiting” strategy, meaning prescribing an antibiotic can and should be deferred for up to 7-10 days after the clinical diagnosis of ARS to ensure that antibiotic therapy is warranted. To reiterate this point, a meta-analysis that included 63 studies, nine placebo-controlled studies and 54 studies comparing antibiotic classes, found that cure or improvement rates in patients with ARS that received antibiotic treatment vs. no treatment was comparable (91% vs. 86%).6
If symptoms are severe, worsen, or persist for 10 days or more, bacterial etiology is suspected and treatment with antibiotic therapy is indicated. Preferred therapy for initial ARS treatment
in adults is amoxicillin-clavulanate and the preferred therapy
for initial treatment in children is amoxicillin (see Table 2). National guidelines recommend the use of high-dose amoxicillin/ clavulanate for severe cases of ARS infection and for patients who are at high-risk for penicillin-resistant S. pneumoniae infection. High-risk patients include the following: age of <2 years or >65 years, attendance at daycare, antibiotic use within the past month, recent hospitalization, and immunocompromised. However, the 2017 Christiana Care Health System antibiogram shows that 97% of S. pneumoniae isolates were susceptible to penicillin, and standard dosing of amoxicillin/clavulanate in adults and amoxicillin in children can typically be utilized. Adults should be treated for 5-7 days, and pediatric patients should be treated for 10 days.3,5
TABLE 1. KEY DIFFERENCES IN ARS ETIOLOGIES2,5
VIRAL
BACTERIAL
• Symptoms peak at 2-3 days and are present <10 days.
• Symptoms may persist for > 10 days, but are expected to decrease in severity. Symptoms do not worsen
• Antibiotics are not indicated for treatment
• Therapy is used for symptom management
• Persistent symptoms (> 10 days) with no signs of improvement
• Severe symptoms or high fever (> 102F) with nasal discharge or facial pain for 3-4 consecutive days
• Worsening symptoms or signs of new fever, headache, or increase in nasal discharge following typical viral upper respiratory tract infection lasting 5-6 days, where symptoms were initially improving (“double sickening”)
• Antibiotic treatment is warranted
26 CHRISTIANA CARE HEALTH SYSTEM
Therapeutic Notes