It is a common scenario in an otolaryngology office: A patient with nasal congestion and a sinus headache wants an antibiotic to eradicate the problem-and quickly. The clinician must often make a judgment call. Should the physician treat empirically with an antibiotic, possibly due to pressure from the patient, or should the physician encourage the patient to explore other options first?
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October 2008The correct answer has several components: Identifying the appropriate treatment involves a series of further questions, and even then, there is more than one good approach. Further, the decision to treat bacterial sinusitis with antibiotics or not is a balancing act between more rapid healing and the risk of promoting antibiotic-resistant organisms, particularly methycillin-resistant Staphylococcus aureus (MRSA).
In separate phone interviews, two experts discussed the latest thinking about treating bacterial sinusitis with antibiotics.
Diagnosis Is Key
There are three questions the otolaryngologist needs to ask before prescribing an antibiotic for sinusitis, said Richard M. Rosenfeld, MD, MPH, Professor of Otolaryngology at State University of New York-Downstate Medical Center in Brooklyn. The first question to ask is, does the patient have sinusitis? he said. Is the patient’s clinical presentation consistent with a diagnosis of sinusitis?
The second question asks whether the infection is viral or bacterial. The third and final question addresses the appropriateness of antibiotics.
Dr. Rosenfeld noted the definition of acute sinusitis in the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) clinical practice guidelines: A patient who has purulent anterior or posterior nasal drainage for up to four weeks, as well as nasal obstruction or facial pain or pressure, is considered to have acute sinusitis.1
Otolaryngologists are in an excellent position to be thorough in the diagnostic workup, said Jack B. Anon, MD, Clinical Professor of Medicine in the Department of Otolaryngology at the University of Pittsburgh College of Medicine. The trained otolaryngologist is the best physician to make this diagnosis, he said.
Viral or Bacterial?
The first, obvious step is to get the history of the condition and the patient’s overall medical history. If the patient’s symptoms meet the AAO-HNS standards, the physician next asks the second question: Is the infection viral or bacterial? According to the AAO-HNS guidelines, a sinus infection is likely to be bacterial in two circumstances: if it persists for 10 days or more without improvement, or if a double worsening pattern is present, according to Dr. Rosenfeld.1
The double worsening pattern in sinusitis occurs when a patient seems to be recovering and then relapses, he said. When double worsening occurs, the otolaryngologist should be suspicious of a bacterial infection even if 10 days have not elapsed. Dr. Rosenfeld said that these clinical observations are sufficient for diagnosing bacterial sinusitis, and that nasal endoscopy and imaging studies are not necessary.
Dr. Anon agreed with Dr. Rosenfeld about the standard for suspecting bacterial sinusitis. However, he has a different approach for the use of diagnostic technology. Nasal endoscopy and cultures, if we see drainage in the middle meatus or superior meatus, are also tools in our armamentarium, he said.
In his research, Dr. Anon has found plain film X-rays, while lacking the sensitivity of computed tomography (CT), to be a benefit, in that the physician can confirm the presence or absence of disease within the maxillary and frontal sinuses.
Faster Healing versus Risk of Adverse Events
Drs. Anon and Rosenfeld agreed that the answer to the third question, whether to treat with antibiotics, is not answered as simply as the first two. The difference in their perspectives reflects the sea change that is occurring regarding antibiotic treatment of sinusitis.
Some physicians question the need for antibiotics in acute sinusitis, Dr. Anon said. He noted that one of the problems is in the way patients are selected for placebo-controlled trials, an issue that has been addressed recently in the literature.2
Most clinical studies will include patients with viral disease, which is self-resolving. Also, 60 percent of bacteriological sinus disease will self-resolve, he said.
Noting that the goal of an antibiotic is to get rid of bacterial disease, he said that otolaryngologists can use the acute otitis media literature as a model for sinusitis. The literature on otitis media is more plentiful because of the ease of obtaining cultures from an ear rather than from the sinus. In the otitis media setting, the literature shows that patients with a bacterial infection have better outcomes with effective antibiotics than without.
In his practice, Dr. Anon chooses the antibiotic with the best pharmacokinetics and pharmacodynamics for the sinuses. His treatment choices include amoxicillin clavunate with additional amoxicillin as a first-line approach. For penicillin-allergic patients, he uses levofloxacin or moxifloxacin. His own research shows that, in particular, levofloxacin is an effective alternative treatment for bacterial sinusitis.3
We have shown in several studies that levofloxacin will sterilize Haemophilus influenzae with one 750-mg dose, he said. Streptococcus pneumoniae requires about three days of treatment before the organism has been eradicated.
He stressed that managing patient expectations is an important part of antibiotic therapy for sinusitis. For example, physicians should inform their patients that significant inflammation typically accompanies sinusitis. Therefore, they may not feel completely better with antibiotics alone. If the patient is using amoxicillin clavunate plus amoxicillin, Dr. Anon also prescribes a week of treatment with prednisone to address the inflammation.
Treatment of inflammation is more complicated when the patient is treated with fluoroquinolones, because they have been associated with rupture of the Achilles tendon. Therefore the Food and Drug Administration (FDA) has issued a black box warning for the drug.4 Patients on fluoroquinolones should not receive concomitant corticosteroids, he said. To minimize the risk of tendon rupture, Dr. Anon has recommended magnesium supplements to patients on fluoroquinolones.
A Challenging Balance
The issues to consider are the severity of the infection and the patient’s thoughts regarding the benefits of antibiotic treatment compared to the risk of adverse events, said Dr. Rosenfeld.
To gauge the severity, the physician must consider both objective and subjective information. The infection is considered mild if the patient’s temperature is less than 101° F and pain is not severe. With mild sinus infections, we know from randomized trials that 73 percent of patients improve on their own in seven to 12 days whether they receive the antibiotic or the placebo. If you treat such infections with an antibiotic, you increase the resolution 14 percent-from 73 percent to 87 percent.
We have shown in several studies that levofloxacin will sterilize Haemophilus influenzae with one 750-mg dose. Streptococcus pneumoniae requires about three days of treatment before the organism has been eradicated.-Jack B. Anon, MD
The question to ask the individual patient with mild sinusitis is: Are the treatment and the risk of adverse events worth the extra 14%? The adverse effects are primarily gastrointestinal upset, rashes, and allergic reactions, Dr. Rosenfeld said. More women than men get sinusitis; therefore, another potential adverse effect is yeast vaginitis. The physician needs to know whether, for a patient with mild sinusitis, these risks are worth the potential for improving three to four days faster.
If the patient is relatively comfortable despite the sinusitis, it’s very reasonable to watch and wait and see if the sinusitis resolves, he said. He added that the patient may have some professional or personal issues that would make a stronger case for antibiotic treatment. For example, if the patient has an airplane trip coming up or is a professional singer and needs to clear the sinuses as quickly as possible to be able to perform, antibiotic treatment would have some appeal. This needs to be a shared decision with the patient, Dr. Rosenfeld said.
However, if the infection is more severe, watching and waiting is not advisable. Those patients have been excluded from most clinical trials by definition, he said.2 When we say patients get better on their own, those are patients who have to have mild sinusitis to have been included in the trials.
He added that physicians should not confuse the forgoing of antibiotics with no treatment at all. Just because you’re not giving the antibiotic doesn’t mean you aren’t treating, he stressed.
Some alternative effective remedies include saline irrigation, nasal steroids, and oral and topical decongestants. For saline irrigation, patients should use a solution of 1 teaspoon of salt per 8 ounces of water. The patient can then use a syringe to spray the solution up the nose. Nasal steroid sprays are equal to antibiotics in efficacy in mild sinusitis, Dr. Rosenfeld said.3 Nonprescription oral or topical decongestants can also help; in the case of topical decongestants, patients should not use them for more than three days, he stressed.
If patients are persistent about their desire for an antibiotic, education about antibiotic resistance may require some frankness. I tell the patient, you may feel better quicker, but if you get sick again, you will have more resistant bacteria that are tougher to treat, and this process will continue until you get a serious infection, Dr. Rosenfeld said. We would like to reserve antibiotics for more severe cases.
WASP and SNAP
A compromise can be the wait and see prescription (WASP). With WASP, the physician writes the prescription and gives it to the patient, but asks the patient to wait until seven days have passed or worsening occurs before filling the prescription. The physician can then ask the patient to consider letting the infection resolve naturally if he or she is getting better. Another term for this approach is the safety net antibiotic prescription (SNAP) (see sidebar).
People have been very receptive if you take the time to explain, Dr. Rosenfeld said. Unfortunately, with the pressures of managed care, WASP is not particularly a quick sell. That’s why physicians feel the pressure to just write the script. It doesn’t take that much time to explain WASP, though, and most patients are receptive, if they know the reasoning behind the wait.
He said that having antibiotics that work when we need them is a key motive behind WASP. It doesn’t serve anyone to create superbugs by treating mild infections with antibiotics, he said. If the patient is not comfortable with WASP, go ahead and use antibiotics, but at least have the conversation and give them the option. Use antibiotics only in those patients in whom you’ve made the right diagnosis. This approach makes it more likely to that you’ll use antibiotics more judiciously.
WASP and SNAP
Two acronyms, WASP and SNAP, have been used to describe the compromise approach in antibiotic treatment of sinusitis:
- Wait And See Prescription and
- Safety Net Antibiotic Prescription.
WASP and SNAP, which are identical approaches, can help the physician accommodate patient preferences and prudent use of antibiotics, said Richard M. Rosenfeld, MD, MPH. When exercising WASP/SNAP, the physician writes the prescription, but asks the patient to wait before filling it. The patient is asked to take the prescription to the pharmacy for filling only after either seven days with no improvement or worsening symptoms, even if seven days have not passed since the prescription was written.
This compromise approach also facilitates patient-physician communication and trust, he added. The patient trusts the physician to deliver quality care and attend to his or her concerns. The physician, in turn, trusts the patient to adhere to the terms of WASP/SNAP by only filling and using the prescription under the stated circumstances. Therefore, the physician bypasses an impasse of patient preferences and prudent medical care, and instead brings the patient into the decision, Dr. Rosenfeld said.
References
- Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137:S1-37.
[Context Link] - Marple BF. Dilemma in trial design: do current study designs adequately evaluate effectiveness antibiotic antibiotic in ABRS? Otolaryngol Head Neck Surg 2005; 133:200-1.
[Context Link] - Williamson IG, Rumsby K, Benge S, et al. Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: a randomized controlled trial. JAMA 2007;298:2487-96.
[Context Link] - www.fda.gov/cder/drug/infopage/fluoroquinolones/default.htm .
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