Acute rhinosinusitis

Acute rhinosinusitis

2012EPOS 2012IDSAGuidelineforABRS

Sasikarn Suesirisawad, MD

2007EPOS: VS 2012

Content 2007 2012

Definition Divided into adult/children

Classification Acute non-viral rhinosinusitis

Acute post viral rhinosinusitis

Defined ABR

Epidemiology More study

Factor associated with ARS

More evidence

Additional lab Mucocillary functionNasal airway assessment

ProcalcitoninESR

Algorithm andEvidence of treatment

Transformation

ARS in primary care studi es

0.2 -1.8%

3.4 %

6-10%

14%

Recurrent ARS: 0.035%

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16.4%

1.4%

7%

ARS in secondary care st udies

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EPOS: Categories of Evidence

Ia: - meta analysis of RCTS

Ib: at least 1x RCT

IIa: at least 1x controlled study w/out ran

domization

IIb: -at least 1x other type of quasi experi

mental study

III: - non experimental descriptive studies

IV: expert opinion

EPOS: Strength of Recommendations

A = directly based on category I eviden

ce

B = directly based on category II eviden

ce, or extrapolated from category I evid

ence

C = directly based on category III evide

nce or extrapolated from category I or II

evidence

D = directly based on category IV evide

nce or extrapolated from category I, II o

r III evidence

Acute rhinosinusitis in adults Inflammation of nose and paranasal s

inuses

≥ 2 symptoms, one of nasal blockage /obstruction/congestion or nasal disc

harge (ant/post nasal drip):

± facial pain/pressure

± reduction or loss of smell

And either

endoscopic signs of:

nasal polyps, and/or

mucopurulent discharge from middle me atus and/or

edema/mucosal obstruction in middle meatus

and/or

CT changes:

mucosal changes within ostiomeatal co mplex and/or sinuses

For <12 weeks

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Acute rhinosinusitis in children

Inflammation of nose and paranasal s inuses

≥ 2symptoms one of nasal blockage/ obstruction/congestion or nasal disch

arge (ant/post nasal drip):

± facial pain/pressure

± cough

And either

endoscopic signs of:

nasal polyps, and/or

mucopurulent discharge from middle me atus and/or

edema/mucosal obstruction in middle meatus

And/or

CT changes:

mucosal changes within the ostiomeatal complex and/or sinuses

12For < weeks

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Conventional Criteria for Diagnosis of Sinusitis

2 1Based on Presence of at Least Major or M 2ajor and Minor Symptoms

IDSA Guideline for ABRS: CID.March 20, 2012

Severity of disease in adult and children

Definedi sease sever i t y:

Mild: -03VAS

Moderate: -47VAS

Severe: -810VAS

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Classification of ARS in adult/children Common cold/ acute viral rhinosinusits :

duration of symptoms for< 1 0 d

- Acutepostviralrhinosinusitis: increaseofsymptomsafter5d or per si st 10 12ent symptoms after d with < wk duration.

3ABS: ≥ symptoms/signs

Discoloured discharge (unilat predominance) and purulent secre tion in nasi

Severe local pain (unilat predominance)

Fever (>38 °C)

Elevated ESR/CRP

‘ Double sickening’ (deterioration after initial milder of illness)

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Natural history & time course of fever and RS sym ptom associated with uncomplicated viral URI in c

hildren


Acute rhinosinusitis can be divided into Common Coldand postviral rhinosinusitis. A small subgroup of post-

viral rhinosinusitis is caused by bacteria (ABRS).EPOS March 2012

Signs of ABSAt least 3 of:-Discoloured d/c-Severe local pain-Fever-Elevated ESR/CRP-Double sickening

Postviral acute rhinosinusitis

Increase in symptoms after 5 d

Persistent symptom after 10 d

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I: Which clinical Presentations Identify

Acute Bacterial Vs Viral Rhinosinusi tis ? OnsetwithpersistentS/Scompatiblewi t h ARS ≥ 10d wi t hout any evi dence

of clinical improvement.

3Onset with severe S/S of high fever ≥ 9 34°Candpurulentnasaldischargeor f aci al pai n at l east – consec

utive d at beginning of illness.

Onset with worsening S/S characterized b ooooo oo oooooo ooooooooo oooooooo o, , n nasal discharge following typical viral U ooo o ooo o ooo ooooooooo oo oo5 – 6

oving (‘‘doublesickening’’).


Factors associ atedwi thARSooooooooooooo ooooooooooooooo oooo oooooooAllergy

Ciliary impairment

ooooooo ooooo ooooooooooSmoking

Laryngopharyngeal reflux

Anxiety and depression

Drug resistance

Concomitant Chronic Disease

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Environmental Exposures Exposure to individual with respirator

y complaints was risk factor for RS in fection(adjusted OR = 3.7).

Increased levels of dampness in hom e has been associated with sinusitis.

Exposure to air pollution, irritants use d in preparation of pharmaceutical pr

oducts, during photocopying and fore st fire smoke.

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Anatomical factors

Anatomical variations including Halle r cells and septal deviation, nasal pol

yps, and choanal obstruction by beni gn adenoid tissue, or odontogenic so

urces of infections.

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Ciliary impairment

Ciliary function diminished during vir al and bacterial rhinosinusitis.

Exposure to cigarette smoke and alle rgic inflammation has been shown to

impair ciliary function.

Impaired mucociliary clearance in AR patients predisposes patients to ARSEPOS March

2012

Smoking

- Active smokers with on going allergic inflammation have increased suscept

-ibility to ARS compared to non smoke - rs with on going allergic inflammatio

n, suggest i ng t hat exposur e t o ci ga rette smoke and allergic inflammatio

n is mediated via different and possib ly synergistic mechanisms.

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Laryngopharyngeal reflux - - Pacheco Galvan et al. 1997 2006 hav

e shown significant associations betw o ooo ooo oooooooooo .

Recent systematic review, Flook andooo oo oooo oo oooo oooo ooooooooooo

between acid reflux, nasal symptoms , and ARS

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Anxiety and depression

Poor mental health, anxiety, or depre ssion is associated with susceptibility

to ARS

ooo oooooooo.

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Drug resistance

Amoxicillin is the most commonly use d antibiotic for mild ARS.

Increasing resistance to amoxicillin, p articularly in S. pneumoniae and

ooooooooooo. .

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Concomitant Chronic Disease Concomitant chronic disease (bronch

itis, asthma, CVS disease, DM, CA) in children has been associated with inc

reased risk of developing ARS second ary to influenza.

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Microbiologyofviral(commoncol d),postvi ral ,andbac terial ARS

.

Rhinoviruses (50%) and coronaviruses.

Influenza viruses, parainfluenza viruses, adenovirus, RSV, enterovirus.

.

S. pneumoniae, Haemophilus influenza, M. catarrhalis and S. aureus.

Streptococcal species , anaerobic bacteria

ABRS generally preceded by viral and - or post viral ARS.

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Investigation

Bacteriology

Microbiological investigations are notoooooooo ooo ooooooooo oo ooo oo ooooo

ooooooooo .

May be required in research settings, or in atypical or recurrent disease

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Prevalence (Mean Percentage of Positive Sp ecimens) of Pathogens From Sinus Aspirate

s in ABS


XVI. Should Cultures Obtained by Sinus Punct ure or Endoscopy, Cultures of Nasopharyngea

l Swabs Sufficient?

Cultures be obtained by direct sinus aspi ration rather than by nasopharyngeal sw

ab (strong, moderate).

Endoscopically guided cultures of middle meatus may be considered as alternativ

e in adults, but their reliability in children has not been established (weak, mode

rate).

o ooooooooooooo oooooooo ooo oooooooooo and are not recommended for microbiolo

gic diagnosis of ABRS (strong, high)


- C Reactive Protein (CRP)

Raised in bacterial infection.

Limiting unnecessary antibiotic use.

ARS: low or normal CRP may identify l ow likelihood of positive bacterial infe

ooooo

CRP levels are significantly correlate d with changes in CT scans.

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ESR

ESR levels correlated with CT change s in ARS

ESR >10 is predictive of sinus fluid le

vels or sinus opacity on CT scan.

Raised ESR is predictive of positive boooooooo ooooooo oo ooooo oooooooo oo oavage EPOS March

2012

Procalcitonin

More severe bacterial infection

There is no evidence of its effectiven ess as a biomarker in ARS.

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Nasal Nitric Oxide (NO)

Sensitive indicator of presence of infl ammation and ciliary dysfunction.

Very low levels: primary ciliary dyskin esia, insignificant sinus obstruction.

Elevated levels: inflammation provid ed ostiomeatal patency maintained.

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Nasal endoscopy

Nasal endoscopy may be used to visu alize nasal and sinus anatomy and to

provide biopsy and microbiological sa.

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Imaging

CT scan

Modality of choice to confirm extent of pa thology and anatomy.

-Very severe disease, immuno compromis ed pt, suspicion of complications.

Routine CT scan in ARS little useful information

Plain sinus X Rays

Insensitive & limited usefulness

oooooooooo Insensitive & limited usefulness

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XVII. Which Imaging Is Most Useful for S evere ABRS who suspected to have Sup

purative complication? CT rather than MRI is recommended t

o localize infection and to guide furth er treatment (weak, low).


Differential Diagnosis of ARS

Viral Upper Respiratory Tract Infectioo

Allergic rhinitis

Orodontal disease

Rare diseases

Intracranial sepsis

Facial pain syndromes

Vasculitis

Acute invasive fungal rhinosinusitis

CSF leak

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Warni ngsi gns of compl i cati ons of ARS

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Management of ARS

ARS resolves without antibiotic treat oo o ooo oooooo .

Symptomatic treatment and reassura nce is the preferred initial manageme

nt strategy for patients with mild sym.

Antibiotic therapy should be reserved for high fever or severe (unilateral) fa

ooooo.

For initial treatment, the most narrow- spectrum agent active against the li

kely pathogens (S. pneumoniae and H. influenzae) should be used.

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Empiric ATB be initiated as soon as cli nical diagnosis of ABRS is established

as defined in recommendation 1 (stro ng, moderate)

II: When Should ATB Initiated

in Pt With S/S Suggestive of ABRS?

IDSA Guideline for ABRS: CID. March 20, 2012

III: Should Amoxicillin Vs A- moxi Clav Used for Initial ATB o

f ABR in Children? - Amoxi clav rather than amoxicillin alooo ooooo o ooooo oo oo ooooo ooooo o

crobial therapy for ABRS in children

(strong, moderate).


IV: Should Amoxicillin Vs A- moxi Clav used for Initial ATB of ABR in adults? - Amoxi clav rather than amoxicillin al one is recommended as empiric ATB f

or ABRS in adults

(weak, low).


- -V: When Is High Dose Amoxi Cla v Recommended Initial ATB for

ABR ?‘‘ - -High dose’’ (2 g/d or 90 MKD bid) amoxi

clav recommended for children and adult

s with ABRS

High endemic rates (≥10%) of DRSP

Severe infection

( systemic toxicity with fever ≥ 39 °C, a

nd threat of suppurative complications)

Attendance at daycare

Age <2 or > 65 years

Recent hospitalization

Antibiotic use within the past month

Immunocompromised


- - VI: ShouldquinoloneVsB Lact amused 1° l i ne f or I ni t rrr rr rrrr?

- - B lactam (amoxi clav) rather than res piratory fluoroquinolone recommend

ed for initial empiric antimicrobial the rapy of ABR

(weak, moderate)


VII: Besides quinolone, Should Macrolide , bactrim, doxycycline, 2°/3° Gen Cep Us

- ed 2 ° line for ABR? Doxycycline may be used alternative in adults because it remains a

ctive against RS pathogens and has excellent PK/PD (weak, low).

2°/3° oral Gen Cep: no longer recommended for empiric monothera

py of ABRS due to resistance S. pneumoniae. Combination tx with

- 3° oral Gen plus clindamycin may be used as 2° line for children wi

th non–type I penicillin allergy or high endemic rates of PNS S. pneu

moniae (weak, moderate).

Not recommended

30Macrolides: high rates of resistance S. pneumoniae ( %) (strong, moderate)

/: .&.( 3– 40%) (,)


VIII. Which ATB Recommended f or ABRS in Adults/Children with

Penicillin Allergy? Adults:

Either doxycycline or quinolone(levofloxacin/moxifloxacin)

(strong, moderate)

Children:

Levofloxacin: type I hypersensitivity to penicillin

Clindamycin + 3° oral Gen Cep (cefixime/cefp odoxime): non–type I hypersensitivity to penic

illin

(weak, low)


rrrrrrrr rrr rr rrrrrr rr rrrrrrrr rrrrrrrr: . y during Initial Empiric ATB of ABR?

S. aureus (including MRSA) is one of potential pathogen in ABRS

Routine ATB coverage for S. aureus o r MRSA during initial empiric therapy

of ABRS is not recommended (strong, moderate).


X: Should empiric ATB be admin istered for 5 –7 d vs 1 0 –1 4 d

? Uncomplicated ABRS in adults: 5–7 d -ays (weak, low moderate).

Children with ABRS: 10–14 days (weak, low moderate).


XIV: How Long Should Initial Empiric ATr rr rrrrrrr rr rrrrrrrr rr rrrrrr rrr rr rrr

tinued Before Considering AlternativeManagement? Alternative management strategy is r

ecommended if symptoms worsen aft er 48–72 hrs of initial empiric ATB or f 35ail to improve despite – d of initial

oo ooooo ooo

(strong, moderate)


XV: What Is Recommended in Who Worsen D espite 72 Hr or Fail to Improve After 3–5 D of Initial Empiric ATB?

Should be evaluated for possibility of resistant pathogens, noninfectious et

iology, structural abnormality, or oth er causes for treatment failure

(strong, low).


INS in ARS

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INS & ATB in ARS

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XII: Are INS Recommend ed as Adjunct to ATB in A

BR? INS recommended as adjunct to ATB, primarily in patients with history of A

o

(weak, moderate)


Oral corticosteroids adju nct therapy

Cochrane analysis suggests that oral steroids as adjunctive therapy to oral

-antibiotics are effective for short ter m relief of symptoms (headache, faci al pain, nasal decongestion and) in A

oo

Evidence level Ia

EPOS March 2012

Oral antihistamines

No indication for use of AH(both intra nasal and oral) in treatment of post vi

- ral ARS, except in co existing allergic.

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Nasal decongestants

27 5117trials ( , participants) of RCT: eff ectiveness of common cold treatments

- AH, analgesic decongestant combinati ons have some general benefit in adult

s and older children (recommendationA).

ooooooo oooooooo ooooooo oooo oo ooooooo oo

fects.

No evidence of effectiveness in young.

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XIII: Should Topical or Oral Decongestarrr rr rr rr r rrr rr rrrrrrrrrr rr rr r?

Neither topical nor oral decongestant s and/or AH recommended as adjunct

ive treatment in patients with ABRS ( -strong, low moderate).


Nasal or antral irrigation

Nasal douching with saline solution h as limited effect in adults with ARS

(level of evidence Ia).

Effective in children with ARS in addit ion to standard medication (level of e

vidence Ib) and can prevent recurren t infections (level of evidence IIb

)EPOS March 2012

XI: Is Saline Irrigation of B enefit as Adjunctive Tx in A

BR? Intranasal saline irrigation(physiologi c /hypertonic saline) recommended a s an adjunctive treatment in adults wi -th ABRS (weak, low moderate).


Heated, humidified air

Steam may help congested mucus dr ain better and heat may destroy cold

virus as it does in vitro.

Steam inhalation has not shown any consistent benefits in treatment of co

ooooo ooooo oo ooo ooooo o ooo, ed in routine treatment of common c old symptoms

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Ipratropium bromide

Likely to be effective in ameliorating r .

Recommendation A

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Probiotics

Probiotics were better than placebo i n reducing number of acute URTIs, ra te ratio of and reducing antibiotic use

Recommendation A

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Vaccination

No direct effect in treatment of ARS.

Affected frequency and bacteriology of AOM and ABS

Causative pathogens of ABS in childr en in 5 y after introduction vaccinatio

n PCV7 as compared to previous 5 y. Proportion of S. pneumoniae dec

18lined by %, H.influenzae increased 8by %

EPOS March 2012

NSAID’s, Aspirin or acetominophen NSAID did not significantly reduce TS

S, or duration of colds.

Outcomes related to analgesic effect s of NSAID (headache, ear pain, musc

le, jt pain).

No evidence of increased frequency o

f adverse effects in NSAID tx groups.

Recommend NSAID for relieving disc

omfort or pain caused by common colo

EPOS March 2012

Zinc

oooo ooooo ooooooo oooooooo oo ooooooo of common cold and prevention risk o

f developing episode of common cold.

Too early to give general recommend

ations for use of zinc because not suf ficient knowledge optimal dose, form ulation and duration of treatment

Recommendation C

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Algorithm for manag

ement of ABS


EPOS March 2012

EPOS2007

Treatment adult with ARr

EPOS2007

EPOS March 2012

EPOS2007

Treatment children withARS

EPOS 2007

80-90MKD40-50MKD

THANK YOU

Indications for Referral to Specialist


Health & Medicine

Acute rhinosinusitis