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Acute Bacterial Sinusitis: Acute Bacterial Sinusitis: Evaluation and Management in the Adult Evaluation and Management in the Adult

Troy D. Woodard MD, FACSTroy D. Woodard MD, FACS

Kathleen Kathleen YappelYappel SinkkoSinkko CNP, MSNCNP, MSN

�� Troy Woodard, MDTroy Woodard, MD

–– Consultant for MedtronicConsultant for Medtronic

�� Kathleen Kathleen YappelYappel SinkkoSinkko CNP, MSNCNP, MSN

–– NoneNone

DisclosuresDisclosures

ObjectivesObjectives�� Identify normal nasal and sinus anatomyIdentify normal nasal and sinus anatomy

�� Define the term Define the term rhinosinusitisrhinosinusitis/sinusitis/sinusitis

�� Identify at least 2 major and 2 minor symptoms of Identify at least 2 major and 2 minor symptoms of rhinosinusitisrhinosinusitis

�� Distinguish at least one different characteristic between Distinguish at least one different characteristic between viral and bacterial sinusitisviral and bacterial sinusitis

�� Participate in a discussion of the treatment of the patient Participate in a discussion of the treatment of the patient who presents with acute bacterial sinusitiswho presents with acute bacterial sinusitis

Nasal StructuresNasal Structures

�� TurbinatesTurbinates

--inferiorinferior

--middlemiddle

--superiorsuperior

�� SeptumSeptum

�� Olfactory cleftOlfactory cleft

What is the function of What is the function of the nose?the nose?

�� BreatheBreathe

�� Warm, Clean, and Humidify the Air Warm, Clean, and Humidify the Air

�� Aid in taste and smellAid in taste and smell

Paranasal sinusesParanasal sinuses

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Possible Possible Functions of Functions of SinusesSinuses

�� Providing a buffer against blows to the faceProviding a buffer against blows to the face

�� Decreasing the weight of the skull and face Decreasing the weight of the skull and face

�� Increasing resonance of the voiceIncreasing resonance of the voice

�� Insulating structures from rapid Insulating structures from rapid temperature fluctuations temperature fluctuations

�� Flotation of skull in waterFlotation of skull in water

�� Humidifying and heating of inhaled air Humidifying and heating of inhaled air

�� Regulation of intranasal and serum gas Regulation of intranasal and serum gas pressures pressures

�� Immunological Defense Immunological Defense

Possible Functions of Possible Functions of SinusesSinuses

EpidemiologyEpidemiology

�� 29.829.8 million nonmillion non--institutionalized institutionalized adults diagnosed with sinusitis adults diagnosed with sinusitis

�� 13%13% of nonof non--institutionalized adultsinstitutionalized adults

�� 12.512.5 million were diagnosed with million were diagnosed with chronic sinusitischronic sinusitis

CDC: 2010 Summary Health Statistics for US AdultsCDC: 2010 Summary Health Statistics for US Adults

$$inuinu$$itiiti$$

�� 3 billion dollars is the 3 billion dollars is the estimated cost of estimated cost of sinusitis in the US sinusitis in the US

What is What is Rhinosinusitis?Rhinosinusitis?

�� The The inflammationinflammation of the nasal lining of the nasal lining and paranasal sinuses.and paranasal sinuses.

Etiology of RhinosinusitisEtiology of Rhinosinusitis

�� Infection (Viral and Bacterial)Infection (Viral and Bacterial)

�� AllergiesAllergies

�� Environmental factors (Smoking, Pollution, Irritants)Environmental factors (Smoking, Pollution, Irritants)

�� Structural abnormalities (Deviated septum, Nasal mass, Structural abnormalities (Deviated septum, Nasal mass, Concha)Concha)

�� Autoimmune (Wegner’s, Sarcoidosis, Sjogren’s)Autoimmune (Wegner’s, Sarcoidosis, Sjogren’s)

�� Immunodeficiency Immunodeficiency

�� Cystic Fibrosis, Primary ciliary dyskinesia Cystic Fibrosis, Primary ciliary dyskinesia

�� GERDGERD

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History is Important!History is Important! Acute vs. Chronic SinusitisAcute vs. Chronic Sinusitis

�� Acute Acute -- up to 4 weeksup to 4 weeks

�� Subacute Subacute -- > 4 weeks but < 12 weeks> 4 weeks but < 12 weeks

�� Chronic Chronic -- > 12 weeks> 12 weeks

Sinusitis SymptomsSinusitis Symptoms

�� Major SymptomsMajor Symptoms–– Purulent anterior nasal dischargePurulent anterior nasal discharge

–– Purulent or discolored posterior nasal dischargePurulent or discolored posterior nasal discharge

–– Facial congestion of fullnessFacial congestion of fullness

–– Facial pain or pressureFacial pain or pressure

–– Hyposmia or anosmiaHyposmia or anosmia

–– Fever (for acute sinusitis only)Fever (for acute sinusitis only)

Obtained from IDSA Guidelines March 20, 2012Obtained from IDSA Guidelines March 20, 2012

Sinusitis symptomsSinusitis symptoms

�� Minor SymptomsMinor Symptoms–– HeadacheHeadache

–– Ear pain, pressure, or fullnessEar pain, pressure, or fullness

–– HalitosisHalitosis

–– Dental painDental pain

–– CoughCough

–– Fever (for subacute or chronic sinusitis)Fever (for subacute or chronic sinusitis)

–– FatigueFatigue

Obtained from the IDSA Guidelines March 20, 2012Obtained from the IDSA Guidelines March 20, 2012

Acute Sinusitis DiagnosisAcute Sinusitis Diagnosis

�� 22 Major symptomsMajor symptoms

OROR

�� 11 Major and Major and 22 Minor symptoms Minor symptoms

obtained from IDSA Guidelines March 20, 2012obtained from IDSA Guidelines March 20, 2012

Viral vs. Bacterial sinusitisViral vs. Bacterial sinusitis

�� Which scan is viral? Which is bacterial?Which scan is viral? Which is bacterial?

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Viral vs. Bacterial sinusitisViral vs. Bacterial sinusitis

�� You cant distinguish b/w viral (URI) and You cant distinguish b/w viral (URI) and bacterial acute sinusitis on a CT scan bacterial acute sinusitis on a CT scan

Duration of SymptomsDuration of Symptoms

ViralViral

Duration < 7Duration < 7--10 days10 days

BacterialBacterial

Duration > 7Duration > 7--10 days10 days

CharacteristicsCharacteristics

�� ViralViral–– Nasal symptoms and/or cough, scratchy throat. Nasal symptoms and/or cough, scratchy throat.

–– Nasal discharge usually clear and watery, Nasal discharge usually clear and watery, �� may turn thick and then become purulent for several may turn thick and then become purulent for several days, then reverse to clear or dry.days, then reverse to clear or dry.

–– May have fever in first 24May have fever in first 24--48 hours.48 hours.

Duration is < 7Duration is < 7--10 days10 days

Obtained from IDSA Guidelines March 20, 2012Obtained from IDSA Guidelines March 20, 2012

Characteristics of ABRSCharacteristics of ABRS(Acute Bacterial Rhinosinusitis)(Acute Bacterial Rhinosinusitis)

�� Bacterial 3 typical presenatationsBacterial 3 typical presenatations–– Persistent Persistent symptomssymptoms that last > 10 days and don’t that last > 10 days and don’t improve improve (most common presentation)(most common presentation)

–– Severe Severe symptoms, characterized by high fever of at symptoms, characterized by high fever of at least 39 degrees C (102 F) and purulent nasal least 39 degrees C (102 F) and purulent nasal discharge for at least 3discharge for at least 3--4 consecutive days.4 consecutive days.

–– Worsening Worsening symptoms, characterized by typical URI symptoms, characterized by typical URI symptoms that appear to improve and then get worse symptoms that appear to improve and then get worse again after 5again after 5--6 days6 days (“double(“double--sickening”)sickening”)..

Obtained from the IDSA Guidelines March 20, 2012Obtained from the IDSA Guidelines March 20, 2012

Physical ExamPhysical Exam

�� Vital signsVital signs

�� HEENT HEENT

�� Respiratory examRespiratory exam

�� Anterior rhinoscopyAnterior rhinoscopy

�� Nasal endoscopyNasal endoscopy

CultureCulture

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Diagnostic testsDiagnostic tests

CultureCulture

Pros:Pros:

�� Identify if there is bacteria in the sinuses, Identify if there is bacteria in the sinuses, thus distinguishing from viral infection.thus distinguishing from viral infection.

�� Direct antimicrobial therapy, particularly Direct antimicrobial therapy, particularly helpful if there is a resistant bacteria, or helpful if there is a resistant bacteria, or patient has had treatment failurepatient has had treatment failure

Diagnostic testsDiagnostic tests

CultureCulture

Cons:Cons:�� Not practical for primary care providers Not practical for primary care providers

–– They see the majority of acute presentations. They see the majority of acute presentations.

�� Unless performed properly can contaminate Unless performed properly can contaminate aspiration and lead to misinterpreted resultsaspiration and lead to misinterpreted results

�� Not cost effective in most acute URI presentationsNot cost effective in most acute URI presentations

Diagnostic testsDiagnostic tests

CT sinus scanCT sinus scan

�� Not appropriate to order for an Not appropriate to order for an uncomplicated URIuncomplicated URI

�� Will not determine is infection is viral Will not determine is infection is viral or bacterialor bacterial

TreatmentTreatment

Graded by:Graded by:

Quality of evidence (high, moderate, low, very low)Quality of evidence (high, moderate, low, very low)

andand

Strength of Recommendation (strong, weak)Strength of Recommendation (strong, weak)

Treatment Recommendations Treatment Recommendations for ABRSfor ABRS

IDSA (Infectious Disease Society of America) Guidelines 2012IDSA (Infectious Disease Society of America) Guidelines 2012

Treatment RecommendationsTreatment Recommendations

�� Empiric antimicrobial treatment is recommendedEmpiric antimicrobial treatment is recommended

�� Amoxicillin clavulanateAmoxicillin clavulanate should be used initially should be used initially

–– Increased resistance (varies from region to Increased resistance (varies from region to region)region)

–– H. flu (beta lactamase producing) was 27%H. flu (beta lactamase producing) was 27%--43%.43%.

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Amoxicillin ClavulanateAmoxicillin Clavulanate

�� Pros: Pros: –– Increased coverage against the Increased coverage against the microorganism that are resistant to microorganism that are resistant to amoxicillin ( H. flu, M. Catarrhalis)amoxicillin ( H. flu, M. Catarrhalis)

�� Cons: Cons: –– Increased cost to adding clavulanate and Increased cost to adding clavulanate and also increased risk of GI effects and rare also increased risk of GI effects and rare hypersensitivity reaction.hypersensitivity reaction.

High Dose Amoxicillin ClavulanateHigh Dose Amoxicillin Clavulanate

�� RecommendedRecommended

–– Regions with high rates of PNS (penicillin Regions with high rates of PNS (penicillin nonsusceptible) S. Pneumoniaenonsusceptible) S. Pneumoniae

–– Severe infection (systemic toxicity fever 102 F or 39 Severe infection (systemic toxicity fever 102 F or 39 degrees Celsius or greater.degrees Celsius or greater.

–– Age >65Age >65

–– ImmunoImmuno--suppresssed patientssuppresssed patients

–– Recent hospitalizationRecent hospitalization

–– Antibiotic use within past monthAntibiotic use within past month

2 g orally twice daily

High Dose Amoxicillin ClavulanateHigh Dose Amoxicillin Clavulanate

Pros:Pros:

--May be helpful in treating pt with May be helpful in treating pt with resistant bacteriaresistant bacteria

Cons:Cons:

--Added costAdded cost

--potential for more adverse effectspotential for more adverse effects

Other Antimicrobial Other Antimicrobial TreatmentsTreatments

�� Flouroquinolones (levofloxacin, moxifloxacin)Flouroquinolones (levofloxacin, moxifloxacin)

–– Very effective against all common respiratory Very effective against all common respiratory pathogens (S.pneumoniae (PNS), H. influenzae, M. pathogens (S.pneumoniae (PNS), H. influenzae, M. catarrhalis)catarrhalis)

�� Reserve for:Reserve for:–– Patients who have failed first line therapyPatients who have failed first line therapy

–– PCN allergyPCN allergy

–– Second line therapy for PNS S.pneumoniaeSecond line therapy for PNS S.pneumoniae

FluoroquinolonesFluoroquinolones

�� Adverse effects:Adverse effects:

dizziness, headaches, seizures, sleep dizziness, headaches, seizures, sleep disorders, peripheral neuropathys, disorders, peripheral neuropathys, photosensitivity with skin rash, disorders of photosensitivity with skin rash, disorders of glucose homeostasis, prolongation of QT glucose homeostasis, prolongation of QT intervals, hepatic dysfunction, intervals, hepatic dysfunction, musculoskeletal complaintsmusculoskeletal complaints

FluoroquinolonesFluoroquinolones

�� Adverse effects (cont):Adverse effects (cont):

Risk of Achilles tendon rupture, Risk of Achilles tendon rupture, tendonitis (increases with age and tendonitis (increases with age and steroid use).steroid use).

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Macrolides, TMPMacrolides, TMP--SMXSMX

�� Previously were recommended as Previously were recommended as alternatives to amoxicillin or alternatives to amoxicillin or amoxicillin clavulanate.amoxicillin clavulanate.

�� Now are Now are no longerno longer recommended recommended because increased resistance among because increased resistance among S.pneumonia and/or H. influenzae.S.pneumonia and/or H. influenzae.

DoxycyclineDoxycycline

�� Remains active against all Remains active against all commoncommon respiratory pathogens.respiratory pathogens.

––S. pneumoniaS. pneumonia

––H. influenzaeH. influenzae

––M. CatarrhalisM. Catarrhalis

..

Oral CephalosporinsOral Cephalosporins

�� 22ndnd and 3and 3rdrd generation oral cephalosporins generation oral cephalosporins are no longer recommendedare no longer recommended–– Variable rates of resistance among S. Variable rates of resistance among S. pneumonia.pneumonia.

�� If they must be usedIf they must be used–– Combination therapy with a 3Combination therapy with a 3rdrd generation and generation and clindamycin in regions with high endemic rates clindamycin in regions with high endemic rates of PNS S. pneumoniaof PNS S. pneumonia..

Adjunctive Treatment in ABRSAdjunctive Treatment in ABRS

�� Intranasal corticosteroidsIntranasal corticosteroids

�� Intranasal saline irrigationsIntranasal saline irrigations

–– Isotonic or hypertonic solutionIsotonic or hypertonic solution

Adjunctive Treatment in ABRSAdjunctive Treatment in ABRS

Not recommended:Not recommended:

�� Oral decongestantsOral decongestants

�� Antihistamines Antihistamines

NonNon--responsive Patientresponsive Patient

�� NonNon--responsiveresponsive

–– No improvement or worsening symptoms No improvement or worsening symptoms after 3after 3--5 days of treatment5 days of treatment

–– Change antibiotics to a different Change antibiotics to a different antimicrobial classantimicrobial class

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Nonresponsive PatientNonresponsive Patient

�� If still nonresponsive:If still nonresponsive:

–– CT scan or MRI to investigate CT scan or MRI to investigate noninfectious causes or complicationsnoninfectious causes or complications

–– Endoscopic culture of the sinuses to Endoscopic culture of the sinuses to direct antimicrobial therapydirect antimicrobial therapy

Special ConsiderationsSpecial Considerations

�� Pts who are immunocompromisedPts who are immunocompromised

�� Severe infection Severe infection –– High persistent fever with temp > 102 FHigh persistent fever with temp > 102 F

–– Orbital edemaOrbital edema

–– Visual changes Visual changes

–– Severe headache Severe headache

–– Altered mental statusAltered mental status

�� Multiple medical problems, drug Multiple medical problems, drug allergies and sensitivities, organ allergies and sensitivities, organ transplant, liver or kidney diseasetransplant, liver or kidney disease

Special ConsiderationsSpecial Considerations

�� Resistant pathogensResistant pathogens

�� Fungal sinusitis or granulomatous diseaseFungal sinusitis or granulomatous disease

�� Multiple recurrent infectionsMultiple recurrent infections

�� Anatomic defects requiring surgical Anatomic defects requiring surgical

interventionsinterventions

�� Significant environmental allergiesSignificant environmental allergies

�� Chronic rhinosinusitis (with or without polyps)Chronic rhinosinusitis (with or without polyps)

�� AsthmaAsthma

Case Presentation 1:Case Presentation 1:

�� 36 year old healthy female36 year old healthy female

–– CC: “My sinuses are killing me!”CC: “My sinuses are killing me!”

–– 2 days of nasal congestion, clear 2 days of nasal congestion, clear drainage, facial pressure, loss of smelldrainage, facial pressure, loss of smell

–– No feverNo fever

–– No coNo co--morbiditiesmorbidities

–– Last treated with abx 1 year ago for URILast treated with abx 1 year ago for URI

�� Examination Examination

–– Normal vital signs, Normal vital signs,

–– Anterior rhinoscopy Anterior rhinoscopy

�� Inflammation of inferior turbinatesInflammation of inferior turbinates

�� Clear mucus Clear mucus

�� Frequently blowing noseFrequently blowing nose

�� Rest of HEENT exam is normalRest of HEENT exam is normal

Case Presentation 1 cont:Case Presentation 1 cont: What is her diagnosis?What is her diagnosis?

Viral RhinosinusitisViral Rhinosinusitis

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Why?Why?

�� 3 major symptoms (Rhinosinusitis)3 major symptoms (Rhinosinusitis)

�� Duration of symptoms is only 2 days Duration of symptoms is only 2 days (Viral)(Viral)

Treatment is supportiveTreatment is supportive

Case Presentation 2:Case Presentation 2:

�� 50 year old male 50 year old male

–– CC: “Stuffy nose”CC: “Stuffy nose”

�� HPI:HPI:

–– Had a “cold” 3 weeks ago with low grade fever, Had a “cold” 3 weeks ago with low grade fever, nasal congestion, facial pressure, loss of smell. nasal congestion, facial pressure, loss of smell. It got better on its ownIt got better on its own

–– Now for the past week, has nasal congestion, Now for the past week, has nasal congestion, yellow mucus, cough, loss of smell. No fever. yellow mucus, cough, loss of smell. No fever. Doesn’t feel like he is improvingDoesn’t feel like he is improving

Case Presentation 2:Case Presentation 2:

�� Hx:Hx:–– DiabetesDiabetes

�� Allergies: Allergies: PcnPcn

�� Examination Examination –– Normal vital signs, Normal vital signs,

–– Anterior rhinoscopy Anterior rhinoscopy �� Inflammation of inferior turbinatesInflammation of inferior turbinates

�� Purulent mucus Purulent mucus

�� Sounds hyponasalSounds hyponasal

�� Rest of HEENT exam is normalRest of HEENT exam is normal

What is his diagnosis?What is his diagnosis?

Acute Bacterial RhinosinusitisAcute Bacterial Rhinosinusitis

Why?Why?

�� 3 major symptoms and 1 minor 3 major symptoms and 1 minor (Rhinosinusitis)(Rhinosinusitis)

�� Duration of symptoms is 3 weeksDuration of symptoms is 3 weeks

–– Double sickeningDouble sickening

�� Fluoroquinolone or DoxycyclineFluoroquinolone or Doxycycline

–– If you use another abx, consider culturing If you use another abx, consider culturing because of resistancebecause of resistance

�� Topical Nasal SteroidTopical Nasal Steroid

�� Saline irrigationsSaline irrigations

How do you treat?How do you treat?

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Thank you!Thank you!