Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background

The following principles of appropriate antibiotic use for adults with acute rhinosinusitis apply to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in adults who are not immunocompromised.Most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especially when unilateral) and purulent nasal secretions. Patients with rhinosinusitis symptoms that last less than 7 days are unlikely to have bacterial infection, although rarely some patients with acute bacterial rhinosinusitis present with dramatic symptoms of severe unilateral maxillary pain, swelling, and fever. Sinus radiography is not recommended for diagnosis in routine cases. Acute rhinosinusitis resolves without antibiotic treatment in most cases. Symptomatic treatment and reassurance is the preferred initial management strategy for patients with mild symptoms. Antibiotic therapy should be reserved for patients with moderately severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis and for those with severe rhinosinusitis symptoms-especially those with unilateral facial pain-regardless of duration of illness. For initial treatment, the most narrow-spectrum agent active against the likely pathogens, Streptococcus pneumoniae and Haemophilus influenzae, should be used.     

Diagnosis and management of acute rhinosinusitis in children

Rhinosinusitis is a common disease in children that is often overlooked. The clinical symptoms of acute rhinosinusitis are nasal blockage or congestion, nasal discharge or postnasal drip (often mucopurulent), facial pain, headache, and reduction in/loss of smell. Direct vision by nasal fibroendoscopy may aid the diagnosis. Regarding imaging criteria, recent consensus documents state that plain sinus x-rays are of limited utility, and CT remains the technique of choice, particularly in children with complications or very persistent or recurrent infections that are unresponsive to medical management. Antibiotics are the primary form of medical treatment for acute bacterial rhinosinusitis, but they should be used when acute bacterial rhinosinusitis presents as persistent or severe disease. This will minimize the number of children with uncomplicated viral upper respiratory tract infections who are treated with antimicrobials. Topical corticosteroids may reduce nasal edema and improve ostial drainage and ventilation of the sinus.     

Judicious antibiotic use and intranasal corticosteroids in acute rhinosinusitis

Most patients with symptoms of acute rhinosinusitis are treated with antibiotics. However, many cases of rhinosinusitis are secondary to viral infections and unlikely to benefit from antibiotic therapy. Inappropriate use of antibiotics in patients with acute nonbacterial rhinosinusitis contributes to the increase in bacterial antibiotic resistance. Consequently, safe and effective alternatives to antibiotics are needed in the treatment of acute rhinosinusitis caused by viral infections. Recent results from controlled trials have shown that intranasal corticosteroids, used in combination with antibiotics or as monotherapy in selected cases, provide significant symptom relief and resolution of acute rhinosinusitis. The use of intranasal corticosteroids in acute rhinosinusitis therefore might reduce the inappropriate use of antimicrobial therapy in acute rhinosinusitis.     

Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults: background

The following principles of appropriate antibiotic use for adults with nonspecific upper respiratory tract infections apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease.1. The diagnosis of nonspecific upper respiratory tract infection or acute rhinopharyngitis should be used to denote an acute infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent. 2. Antibiotic treatment of adults with nonspecific upper respiratory tract infection does not enhance illness resolution and is not recommended. Studies specifically testing the impact of antibiotic treatment on complications of nonspecific upper respiratory tract infections have not been performed in adults. Life-threatening complications of upper respiratory tract infection are rare.3. Purulent secretions from the nares or throat (commonly observed in patients with uncomplicated upper respiratory tract infection) predict neither bacterial infection nor benefit from antibiotic treatment.     

Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults: background

The following principles of appropriate antibiotic use for adults with nonspecific upper respiratory tract infections apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease. 1. The diagnosis of nonspecific upper respiratory tract infection or acute rhinopharyngitis should be used to denote an acute infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent. 2. Antibiotic treatment of adults with nonspecific upper respiratory tract infection does not enhance illness resolution and is not recommended. Studies specifically testing the impact of antibiotic treatment on complications of nonspecific upper respiratory tract infections have not been performed in adults. Life-threatening complications of upper respiratory tract infection are rare. 3. Purulent secretions from the nares or throat (commonly observed in patients with uncomplicated upper respiratory tract infection) predict neither bacterial infection nor benefit from antibiotic treatment.     

Acute Rhinosinusitis in Children

Acute rhinosinusitis in children is a common disorder that is characterized by some or all of the following symptoms: fever, rhinorrhea, nasal congestion, cough, postnasal drainage, and facial pain/headache. It often starts as an upper respiratory tract infection that is complicated by a bacterial infection in which the symptoms worsen, persist, or are particularly severe. The accurate diagnosis of acute rhinosinusitis is challenging because of the overlap of symptoms with other common diseases, heavy reliance on subjective reporting of symptoms by the parents, and difficulties related to the physical examination of the child. Antibiotics are the mainstay of treatment. There is no strong evidence for the use of ancillary therapy. Orbital and intracranial complications may occur and are best treated early and aggressively. This article reviews the diagnosis, pathophysiology, bacteriology, treatment, and complications of acute rhinosinusitis in children.     

Rhinosinusitis in children

Clinical practice guidelines for the management of acute bacterial rhinosinusitis in children were published by the American Academy of Pediatrics in 2001. Changes in the antibiotic susceptibility patterns for the common pathogens causing both acute and chronic rhinosinusitis warrant a reevaluation and update of these recommendations. In addition, there was only a very brief discussion of chronic disease in this publication, with the conclusion that the pathogenesis and management of recurrent or prolonged infection were essentially unknown. Although there are still insufficient data in the literature to develop evidence-based clinical guidelines, a careful review of recent literature and the clinical experience of experts who manage pediatric chronic sinusitis are presented in an effort to provide some specific recommendations and to offer practical treatment options. Factors associated with chronic rhinosinusitis should be addressed individually and include environmental pollution, recurrent viral upper respiratory infections, allergic and nonallergic rhinitis, ciliary dyskinesia, cystic fibrosis, immunodeficiency, gastroesophageal reflux, and anatomic abnormalities.     

Effect of amoxicillin-clavulanate in clinically diagnosed acute rhinosinusitis: a placebo-controlled,double-blind,randomized trial in general practice

BACKGROUND: Acute rhinosinusitis is one of the most common reasons for prescribing antibiotics in primary care. However, it is not clear whether antibiotics improve the outcome for patients with clinically diagnosed acute rhinosinusitis. We evaluated the effect of a combination product of amoxicillin-potassium clavulanate on adults with acute rhinosinusitis that was clinically diagnosed in a general practice setting. METHODS: We conducted a randomized, placebo-controlled, double-blind trial with 252 adults recruited at 24 general practices and 2 outpatient clinics. Each patient had a history of purulent nasal discharge and maxillary or frontal pain for at least 48 hours. Patients were given amoxicillin, 875 mg, and clavulanic acid, 125 mg, or placebo twice daily for 6 days. Main outcome measures were time to cure (primary outcome), number of days during which rhinosinusitis restricted activities at home or work, and frequency of adverse effects (secondary outcomes). RESULTS: The adjusted hazard ratio for the effect of amoxicillin-clavulanate was 0.99 (95% confidence interval [CI], 0.68-1.45) on time to cure and 1.28 (95% CI, 0.80-2.05) in the prespecified subgroup of patients with a positive rhinoscopy result. At 7 days the mean difference between amoxicillin-clavulanate and placebo was -0.29 (95% CI, -0.93 to 0.34) in the number of days with restrictions due to rhinosinusitis and -0.60 (95% CI, -1.41 to 0.21) in patients with a positive rhinoscopy result. At 7 days patients who took amoxicillin-clavulanate were more likely to have diarrhea (odds ratio, 3.89; 95% CI, 2.09-7.25). CONCLUSIONS: Adult patients in general practice with clinically diagnosed acute rhinosinusitis experience no advantage with antibiotic treatment with amoxicillin-clavulanate and are more likely to experience adverse effects.     

Staphylococcus aureus is a major pathogen in acute bacterial rhinosinusitis: a meta-analysis.

BACKGROUND: Acute bacterial rhinosinusitis is a common health problem in the United States. Appropriate recommendations for the treatment of acute bacterial rhinosinusitis are based on the prevalence and expected antimicrobial susceptibilities of specific pathogens. METHODS: A meta-analysis was performed on the English language literature from the period 1990-2006, including prospective studies of antibiotic therapy for acute bacterial rhinosinusitis for which sinus cultures were required in the form of either maxillary sinus taps or middle meatal cultures. Weighted mean culture rates for Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus were abstracted from the included articles and compared according to culture technique. RESULTS: Culture rates (i.e., the percentage of patients with positive culture results) were 32.7% for S. pneumoniae, 31.6% for H. influenzae, 10.1% for S. aureus, and 8.8% for M. catarrhalis. No statistically significant difference was seen between the culture rates for S. aureus and M. catarrhalis. Analysis of the effect of culture technique on the culture rates revealed no statistically significant difference. CONCLUSIONS: The prevalence of S. aureus among sinus cultures warrants its reconsideration as a major pathogen in acute bacterial rhinosinusitis. As a result, increasing trends of drug-resistant strains may complicate antibiotic recommendations.     

Short-Course Therapy for Acute Sinusitis

This review examines the issues surrounding short-course antibiotic therapy of acute sinusitis. Acute bacterial sinusitis is a common community-acquired infection defined as inflammation of one or more paranasal sinuses, most often the maxillary sinus. It is estimated that 0.5-5% of colds are complicated by acute sinusitis. Up to 1 in 20 upper respiratory tract infections is complicated by bacterial sinusitis, most often caused by Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Staphylococcus aureus. Early diagnosis and appropriate antibiotic therapy, in combination with agents that relieve nasal congestion, are important factors in preventing suppurative complications. Left untreated, it could lead to the development of chronic sinusitis or epidural or subdural empyema, brain abscess, or cavernosus sinus thrombosis. Isolation of the causal organism is often lacking in the community setting. Empiric antibiotic therapy should provide adequate coverage against the most important pathogens. Guidelines from different specialist societies based on current scientific knowledge are helpful in making the decision on which drug to use. Recommendations for duration of treatment of acute sinusitis are inconsistent between different guidelines but usually a 10- to 14-day treatment course is recommended.Recognition that the 10- to 14-day duration of therapy is not derived from a strong scientific or medical rationale has led some clinicians to call for shortening the duration of antibiotic therapy for patients with upper respiratory tract infections. Accumulating evidence suggests that short-course (< or =5 days) antibiotic therapy may have equivalent or superior efficacy compared with traditional longer (10-14 days) therapies and offers a number of advantages. Results of a number of clinical trials investigating 5-day therapy with oral cephalosporins, new quinolones or ketolides in acute (presumed) bacterial sinusitis in comparison with traditional 10-day treatment courses have been published demonstrating equivalent efficacy of 5-day and 10-day regimens. The evidence reviewed in this article strongly supports reduction of the traditional 10-day course of antibacterial therapy to a 5-day course for uncomplicated acute maxillary sinusitis in adults. Further research related to the duration of antibacterial therapy for sinusitis is needed in children and in adult patients with frontal, ethmoidal and sphenoidal sinusitis.     

Fundamental and intensive care of acute pancreatitis

Patients who have been diagnosed as having acute pancreatitis should be, on principle, hospitalized. Crucial fundamental management is required soon after a diagnosis of acute pancreatitis has been made and includes monitoring of the conscious state, the respiratory and cardiovascular system, the urinary output, adequate fluid replacement and pain control. Along with such management, etiologic diagnosis and severity assessment should be conducted. Patients with a diagnosis of severe acute pancreatitis should be transferred to a medical facility where intensive respiratory and cardiovascular management as well as interventional treatment, blood purification therapy and nutritional support are available. The disease condition in acute pancreatitis changes every moment and even symptoms that are mild at the time of diagnosis may become severe later. Therefore, severity assessment should be conducted repeatedly at least within 48 h following diagnosis. An adequate dose of fluid replacement is essential to stabilize cardiovascular dynamics and the dose should be adjusted while assessing circulatory dynamics constantly. A large dose of fluid replacement is usually required in patients with severe acute pancreatitis. Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with severe acute pancreatitis. Although the efficacy of intravenous administration of protease inhibitors is still a matter of controversy, there is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications. Enteral feeding is superior to parenteral nutrition when it comes to the nutritional support of patients with severe acute pancreatitis. The JPN Guidelines recommend, as optional continuous regional arterial infusion and blood purification therapy.     

Norovirus-Gastroenteritis

Viruses are the leading cause of acute gastroenteritis. In adults, noroviruses are the most common cause of gastroenteritis in sporadic cases and also in outbreaks whereas rotaviruses account for the majority of cases of viral gastroenteritis in childhood. Noroviruses are frequently associated with outbreaks in hospitals and nursing homes. The clinical manifestations of gastroenteritis include diarrhea and vomiting as the main symptoms. In immunocompromised patients clinical manifestations may be atypical, such as chronic diarrhea, weight loss and malnutrition. Nucleic acid based PCR tests are the mainstay of diagnosis; however, because of the characteristic clinical symptoms, specific viral diagnosis is usually not required. Noroviruses appear to be readily transmissible at relatively low doses, with an infectious dose even as low as 10–100 viruses and viral shedding can occur at extremely high levels up to >?10⁶ viruses/ml. Patients with symptoms consistent with norovirus gastroenteritis are placed on contact precautions or droplet precautions in case of vomiting. Hand hygiene is the most important means of preventing the spread of infection. Disinfectants with efficacy against noroviruses must be used. Norovirus gastroenteritis is usually self-limiting and is treated with supportive measures. In immunocompromised patients a reduction of immunosuppressive therapy should be considered in severe cases.     

Inflammatory Biomarkers During Bacterial Acute Rhinosinusitis

Purpose of Review

Diagnosis of bacterial acute rhinosinusitis is difficult. Several attempts have been made to clarify the diagnostic criteria. Inflammatory biomarkers are easily obtainable variables that could shed light on both the pathophysiology and diagnosis of bacterial acute rhinosinusitis. The purpose of this review article is to assess literature concerning the course of inflammatory biomarkers during acute rhinosinusitis and the use of inflammatory biomarkers in diagnosing bacterial acute rhinosinusitis.

Recent Findings

We included C-reactive protein, erythrocyte sedimentation rate, white blood cell counts, procalcitonin, and nasal nitric oxide in this review and found that especially elevated C-reactive protein and erythrocyte sedimentation rate are related to a higher probability of a bacterial cause of acute rhinosinusitis. Still, normal levels of these two biomarkers are quite common as well, or the levels can be heightened even during viral respiratory infection without suspicion of bacterial involvement.

Summary

Elevated levels of C-reactive protein or erythrocyte sedimentation rate support diagnosis of bacterial acute rhinosinusitis, but due to a lack of sensitivity, they should not be used to screen patients for bacterial acute rhinosinusitis.

     

Emergency diagnosis and treatment of adult meningitis

Despite the existence of antibiotic therapies against acute bacterial meningitis, patients with the disease continue to suffer significant morbidity and mortality in both high and low-income countries. Dilemmas exist for emergency medicine and primary-care providers who need to accurately diagnose patients with bacterial meningitis and then rapidly administer antibiotics and adjunctive therapies for this life-threatening disease. Physical examination may not perform well enough to accurately identify patients with meningitis, and traditionally described lumbar puncture results for viral and bacterial disease cannot always predict bacterial meningitis. Results from recent studies have implications for current treatment guidelines for adults with suspected bacterial meningitis, and it is important that physicians who prescribe the initial doses of antibiotics in an emergency setting are aware of guidelines for antibiotics and adjunctive steroids. We present an overview and discussion of key diagnostic and therapeutic decisions in the emergency evaluation and treatment of adults with suspected bacterial meningitis.     

Pancreatic involvement in fatal human leptospirosis: clinical and histopathological features

Hyperamylasemia has been reported in more than 65% of patients with severe leptospirosis, and the true diagnosis of acute pancreatitis is complicated by the fact that renal failure can increase serum amylase levels. Based on these data we retrospectively analyzed the clinical and histopathological features of pancreas involvement in 13 cases of fatal human leptospirosis. The most common signs and symptoms presented at admission were fever, chills, vomiting, myalgia, dehydratation, abdominal pain and diarrhea. Trombocytopenia was evident in 11 patients. Mild increased of AST and ALT levels was seen in 9 patients. Hyperamylasemia was recorded in every patient in whom it was measured, with values above 180 IU/L (3 cases). All patients presented acute renal failure and five have been submitted to dialytic treatment. The main cause of death was acute respiratory failure due to pulmonary hemorrhage. Pancreas fragments were collected for histological study and fat necrosis was the criterion used to classify acute pancreatitis. Histological pancreatic findings were edema, mild inflammatory infiltrate of lymphocytes, hemorrhage, congestion, fat necrosis and calcification. All the patients infected with severe form of leptospirosis who develop abdominal pain should raise the suspect of pancreatic involvement.     

Recommendations for the diagnosis and treatment of the acute porphyrias

The acute porphyrias, 4 inherited disorders of heme biosynthesis, cause life-threatening attacks of neurovisceral symptoms that mimic many other acute medical and psychiatric conditions. Lack of clinical recognition often delays effective treatment, and inappropriate diagnostic tests may lead to misdiagnosis and inappropriate treatment. We review the clinical manifestations, pathophysiology, and genetics of the acute porphyrias and provide recommendations for diagnosis and treatment on the basis of reviews of the literature and clinical experience. An acute porphyria should be considered in many patients with unexplained abdominal pain or other characteristic symptoms. The diagnosis can be rapidly confirmed by demonstration of a markedly increased urinary porphobilinogen level by using a single-void urine specimen. This specimen should also be saved for quantitative measurement of porphobilinogen, 5-aminolevulinic acid, and total porphyrin levels. Intravenous hemin therapy, started as soon as possible, is the most effective treatment. Intravenous glucose alone is appropriate only for mild attacks (mild pain, no paresis or hyponatremia) or until hemin is available. Precipitating factors should be eliminated, and appropriate supportive and symptomatic therapy should be initiated. Prompt diagnosis and treatment greatly improve prognosis and may prevent development of severe or chronic neuropathic symptoms. We recommend identification of at-risk relatives through enzymatic or gene studies.     

Occipitomental (Waters' view) radiographs from general practice: are they adequate?

Critics maintain that family physicians produce radiographic images of poorer technical quality than radiologists but the impact of lower quality images on patient care is unknown. Two radiologists assessed occipitomental radiographs made in either a general practice or a certified laboratory for 247 patients with clinically diagnosed acute bacterial rhinosinusitis. With an occipitomental radiograph correct positioning is more difficult than with the usual radiographs of chest or extremities commonly made in general practice. Good positioning was less common in radiographs from general practices, with the pyramid projected below the maxillary sinuses in 63% of radiographs from general practice and 79% of radiographs from a certified laboratory. However, a radiographic diagnosis of possible acute maxillary sinusitis was as common in radiographs from general practice (38%) as in radiographs from a certified laboratory (41%). Although routine use is not recommended, family physicians with suitable technical and interpretative skills can use an occipitomental radiograph to rule out acute maxillary sinusitis in difficult cases. With a radiograph that is hard to read the physician should act as if the disease is present or refer the radiograph to a consulting radiologist.     

Therapy in the management of the rhinitis/asthma complex.

Allergic rhinitis is a risk factor for the development of asthma, and, conversely, asthma often is present in patients with rhinitis (17-25% in children and 20-50% in adults). Up to 80% of patients with asthma have allergic, nonallergic, or mixed rhinitis. Gastroesophageal reflux can be identified in 25-50% of patients with asthma and may be asymptomatic. Topical nasal corticosteroids typically reduce rhinitis symptoms more effectively than oral or topically administered histamine 1 antagonists but are similar in terms of ocular symptom reduction. The leukotriene D4 antagonist montelukast, as well as loratadine (29%), has been found to reduce nasal symptoms (27%) but the combination (33%) provided little additional benefit. Subcutaneous injections with a monoclonal anti-immunoglobulin E antibody for ragweed or birch allergic rhinitis have produced few anaphylactic reactions but when reactions occur, they appear 90-120 minutes after the injection. In the patients who received 300 mg of omalizumab every 3 or 4 weeks for ragweed allergic rhinitis, there were 23% fewer mean nasal symptoms than in placebo-treated subjects. In that study, antihistamines but not nasal corticosteroids were used during the study period. Overall, 70.7% of patients reported treatment as good or excellent compared with 40.8% in placebo-treated patients. The impact of omalizumab or other anti-immunoglobulin E therapies on rhinitis and asthma is being investigated. In patients experiencing acute, purulent, rhinosinusitis, treatment with a nasal corticosteroid helps relieve symptoms sooner than antibiotic and decongestant therapy alone. Treatment of rhinitis or rhinosinusitis and gastroesophageal reflux should be part of the management of patients with asthma.