Acute rhinosinusitis


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Acute rhinosinusitis

Presented by Sasikarn Suesirisawad, MD.

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  • European Position Paper on Rhinosinusitis and Nasal Polyps Infectious Diseases Society of America
  • Prevalence: 6-15% of population ABS: 0.5-2.0% of pt
  • Prevalence of ARS of 1.4% reported in 292 pt of URI at Siriraj Hospital. April- October 200 Treebupachatsakul P et al. J Med Assoc Thai. 2006.Aug;89(8):1178-86. This low prevalence may be due to majority of pts with ARS presenting to their primary care provider rather than hospital
  • Acute post-viral rhinosinusitis ใน EPOS 2007 ใช้คำว่า Acute non-viral rhinosinusitis
  • following clinical presentations(any of 3) are recommended for identifying patients with acute bacterial vs viral rhinosinusitis:
  • ABR Who Has Failed to Both 1°&2° line , should Cultures to Document Persistent/Resistant Bacterial Pathogens.
  • Cochrane analysis, 4DBPC studies with total of 1,943 pt support use of INS as monotherapy or adjuvant tx to ATB(evidence level Ia). Higher doses of INS had stronger effect on improvement or complete relief of symp; for MF 400 μg vs 200 μg, (RR 1.10; 95% CI 1.02-1.18 vs RR 1.04; 95% CI 0.98-1.11). No significant adverse events reported and no significant difference in drop-out and recurrence rate for 2 tx gr.
  • Severe=high fever or unilat facial pain
  • *1b(-): 1b study with negative outcome $ Ia(-) Ia level of evidence that treatment is not effective. **A(-): grade A recommendation not to use สมุนไพรอิชิเนเซีย (echinacea) ใช้ป้องกันรักษาหวัดและไข้หวัดใหญ่ เหมือนเดิม : oral ATB, topical steroid, oral ATB and topical steroid, decongestion, mucolytic, oral AH ต่าง : 2012 มี oral steroid เป็น grade A, combination AH analgesic-decongestion gr A, Ipratopium bromide gr A, protbiotic gr A, herbal medicine, ASA, paracetamol A- steam inhalation cromoglycate Zinc c, vit C C, echinacea C Saline irrigate D เป็น A
  • เหมือนเดิม : oral ATB, topical steroid + ATB, saline irrigate ต่าง : topical steroid D เป็น A topical decongestant C เป็น D mucolytic A- AH D
  • Acute rhinosinusitis

    1. 1. Acute rhinosinusitisEPOS 2012IDSA Guideline for ABRS 2012Sasikarn Suesirisawad, MD
    2. 2. EPOS: 2007 VS 2012Content 2007 2012Definition Divided into adult/childrenClassification Acute non-viral rhinosinusitis Acute post viral rhinosinusitis Defined ABREpidemiology More studyFactor associated with ARS More evidenceAdditional lab Mucocillary function Procalcitonin Nasal airway assessment ESRAlgorithm and TransformationEvidence of treatment
    3. 3. ARS in primary care studies 0.2 -1.8% 3.4 % 6-10% Recurrent ARS: 0.035% 14% EPOS March 2012
    4. 4. ARS in secondary care studies 16.4% 1.4% 7% EPOS March 2012
    5. 5. EPOS: Categories of Evidence Ia: meta-analysis of RCTS Ib: at least 1x RCT IIa: at least 1x controlled study w/out randomization IIb: at least 1x other type of quasi-experimental study
    6. 6. EPOS: Strength of Recommendations  A = directly based on category I evidence  B = directly based on category II evidence, or extrapolated from category I evidence  C = directly based on category III evidence or extrapolated from category I or II evidence  D = directly based on category IV evidence or
    7. 7. Acute rhinosinusitis in adults Inflammation of nose and paranasal sinuses ≥ 2 symptoms, one of nasal blockage/ obstruction/congestion or nasal discharge (a nt/post nasal drip): ± facial pain/pressure ± reduction or loss of smell And either EPOS March 2012
    8. 8. Acute rhinosinusitis in children Inflammation of nose and paranasal sinuses ≥ 2 symptoms one of nasal blockage/ obstruction/congestion or nasal discharge (a nt/post nasal drip): ± facial pain/pressure ± cough And either EPOS March 2012
    9. 9. Conventional Criteria for Diagnosis of SinusitisBased on Presence of at Least 2 Major or 1 Major and2 Minor Symptoms IDSA Guideline for ABRS: CID.March 20, 2012
    10. 10. Severity of disease in adult andchildren  Define disease severity:  Mild: VAS 0-3  Moderate: VAS 4-7  Severe: VAS 8-10 EPOS March 2012
    11. 11. Classification of ARS in adult/children Common cold/ acute viral rhinosinusits : duration of symptoms for< 10 d Acute post-viral rhinosinusitis: increase of symptoms after 5 d or persistent symptoms after 10 d wi th < 12 wk duration. ABS: ≥ 3 symptoms/signs  Discoloured discharge (unilat predominance) and purulent secretion in nasi  Severe local pain (unilat predominance)  Fever (>38 °C)
    12. 12. Natural history & time course of fever and RS symptomassociated with uncomplicated viral URI in children IDSA Guideline for ABRS: CID.March 20, 2012
    13. 13. Acute rhinosinusitis can be divided into Common Coldand post- viral rhinosinusitis. A small subgroup of post-viral rhinosinusitis is caused by bacteria (ABRS).
    14. 14. Postviral acute rhinosinusitis Signs of ABS At least 3 of: Increase in symptoms after 5 d -Discoloured d/c -Severe local pain -Fever Persistent symptom after 10 d -Elevated ESR/CRP -Double sickening EPOS March 2012
    15. 15. I: Which clinical Presentations Identify Acute Bacterial Vs Viral Rhinosinusitis ? Onset with persistent S/S compatible with ARS ≥ 10 d without any evidence of clinical improvement. Onset with severe S/S of high fever ≥ 39 °C and purulent nasal discharge or facial pain at least 3–4 consecutive d at beginning of illness. Onset with worsening S/S characterized by new onset of fever,IDSA Guideline for ABRS: CID.March 20, 2012 in nasal dischar headache, increase
    16. 16. Factors associated with ARS Environmental Exposures Anatomical factors Allergy Ciliary impairment Primary Cilia Dyskinesia Smoking Laryngopharyngeal reflux EPOS March 2012
    17. 17. Environmental Exposures Exposure to individual with respiratory complaints was risk factor for RS infection(adjusted OR = 3.7). Increased levels of dampness in home has been associated with sinusitis. Exposure to air pollution, irritants used in preparation of pharmaceutical products, EPOS March 2012
    18. 18. Anatomical factors Anatomical variations including Haller cells and septal deviation, nasal polyps, and choanal obstruction by benign adenoid tissue , or odontogenic sources of infections. EPOS March 2012
    19. 19. Ciliary impairment Ciliary function diminished during viral and bacterial rhinosinusitis. Exposure to cigarette smoke and allergic inflammation has been shown to impair ciliar y function. Impaired mucociliary clearance in AR patients predisposes patients to ARS EPOS March 2012
    20. 20. Smoking Active smokers with on-going allergic inflammation have increased susceptibility to ARS compared to non-smokers with on-goin g allergic inflammation, suggesting that expo sure to cigarette smoke and allergic inflamm ation is mediated via different and possibly s ynergistic mechanisms. EPOS March 2012
    21. 21. Laryngopharyngeal reflux Pacheco-Galvan et al. 1997-2006 have shown significant associations between GERD and sinusitis. Recent systematic review, Flook and Kumar showed only poor association between acid reflux, nasal symptoms, and ARS EPOS March 2012
    22. 22. Anxiety and depression Poor mental health, anxiety, or depression is associated with susceptibility to ARS Mechanisms are unclear. EPOS March 2012
    23. 23. Drug resistance Amoxicillin is the most commonly used antibiotic for mild ARS. Increasing resistance to amoxicillin, particularly in S. pneumoniae and H. influenzae infections. EPOS March 2012
    24. 24. Concomitant Chronic Disease Concomitant chronic disease (bronchitis, asthma, CVS disease, DM, CA) in children has been associated with increased risk of develo ping ARS secondary to influenza. EPOS March 2012
    25. 25. Microbiology of viral (commoncold), postviral, and bacterial ARS  Viruses.  Rhinoviruses (50%) and coronaviruses.  Influenza viruses, parainfluenza viruses, adenovirus, RSV, enterovirus.  Bacteria.  S. pneumoniae, Haemophilus influenza, M. catarrhalis and S. aureus.  Streptococcal species , anaerobic bacteria EPOS March 2012
    26. 26. Investigation
    27. 27. Bacteriology Microbiological investigations are not required for diagnosis of ARS in routine practice. May be required in research settings, or in atypical or recurrent disease EPOS March 2012
    28. 28. Prevalence (Mean Percentage of Positive Specimens)of Pathogens From Sinus Aspirates in ABS IDSA Guideline for ABRS: CID.March 20, 2012
    29. 29. XVI. Should Cultures Obtained by Sinus Puncture orEndoscopy, Cultures of Nasopharyngeal Swabs Sufficient? Cultures be obtained by direct sinus aspiration rather than by nasopharyngeal swab (strong, mo derate). Endoscopically guided cultures of middle meatus may be considered as alternative in adults, but th eir reliability in children has not been established (weak, moderate). IDSA Guideline for ABRS: CID.March 20, 2012
    30. 30. C-Reactive Protein (CRP) Raised in bacterial infection. Limiting unnecessary antibiotic use. ARS: low or normal CRP may identify low likelihood of positive bacterial infection CRP levels are significantly correlated with EPOS March 2012
    31. 31. ESR ESR levels correlated with CT changes in ARS ESR >10 is predictive of sinus fluid levels or sinus opacity on CT scan. Raised ESR is predictive of positive bacterial culture on sinus puncture or lavage EPOS March 2012
    32. 32. Procalcitonin More severe bacterial infection There is no evidence of its effectiveness as a biomarker in ARS. EPOS March 2012
    33. 33. Nasal Nitric Oxide (NO) Sensitive indicator of presence of inflammation and ciliary dysfunction. Very low levels: primary ciliary dyskinesia, insignificant sinus obstruction. Elevated levels: inflammation provided ostiomeatal patency maintained. EPOS March 2012
    34. 34. Nasal endoscopy Nasal endoscopy may be used to visualize nasal and sinus anatomy and to provide biopsy and microbiological samples. EPOS March 2012
    35. 35. Imaging CT scan  Modality of choice to confirm extent of pathology and anatomy.  Very severe disease, immuno-compromised pt, suspicion of complications.  Routine CT scan in ARS little useful information Plain sinus X Rays EPOS March 2012
    36. 36. XVII. Which Imaging Is Most Useful for Severe ABRSwho suspected to have Suppurative complication?  CT rather than MRI is recommended to localize infection and to guide further treatm ent (weak, low). IDSA Guideline for ABRS: CID.March 20, 2012
    37. 37. Differential Diagnosis of ARS Viral Upper Respiratory Tract Infection Allergic rhinitis Orodontal disease Rare diseases  Intracranial sepsis  Facial pain syndromes  Vasculitis EPOS March 2012
    38. 38. Warning signs of complications ofARS EPOS March 2012
    39. 39. Management of ARS ARS resolves without antibiotic treatment in most cases. Symptomatic treatment and reassurance is the preferred initial management strategy fo r patients with mild symptoms. Antibiotic therapy should be reserved for high fever or severeMarch 2012 EPOS (unilateral) facial pain.
    40. 40. Systemic review/meta-analysis for ATB in ARS EPOS March 2012
    41. 41. II: When Should ATB Initiatedin Pt With S/S Suggestive ofABRS? ATB be initiated as soon as clinical  Empiric diagnosis of ABRS is established as defined in recommendation 1 (strong, moderate) IDSA Guideline for ABRS: CID. March 20, 2012
    42. 42. III: Should Amoxicillin Vs Amoxi-ClavUsed for Initial ATB of ABR in  Amoxi-clav rather than amoxicillin aloneChildren? recommended as empiric antimicrobial thera py for ABRS in children  (strong, moderate). IDSA Guideline for ABRS: CID.March 20, 2012
    43. 43. IV: Should Amoxicillin Vs Amoxi-Clav used for Initial ATB of ABR in adults?  Amoxi-clav rather than amoxicillin alone is recommended as empiric ATB for ABRS in ad ults  (weak, low). IDSA Guideline for ABRS: CID.March 20, 2012
    44. 44. V: When Is High-Dose Amoxi-ClavRecommended Initial ATB for ABR ? ‘‘High-dose’’ (2 g/d or 90 MKD bid) amoxi-clav recommended for children and adults with ABRS High endemic rates (≥10%) of DRSP Severe infection ( systemic toxicity IDSA Guideline for ABRS: CID.March 20, 2012
    45. 45. VI: Should quinolone Vs B-Lactam used1°-line for Initial ATB of ABR?  B-lactam (amoxi-clav) rather than respiratory fluoroquinolone recommended for initial empiric antimicrobial therapy of ABR  (weak, moderate) IDSA Guideline for ABRS: CID.March 20, 2012
    46. 46. VII: Besides quinolone, Should Macrolide, bactrim,doxycycline, 2°/3° Gen Cep Used 2° -line for ABR? Doxycycline may be used alternative in adults because it remains active against RS pathogens and has excellent PK/PD (weak, low). 2°/3° oral Gen Cep: no longer recommended for empiric monotherapy of ABRS due to resistance S. pneumoniae. Combination tx with 3° oral Gen plus clindamy cin may be used as 2°-line for children with non–type I penicillin allergy or high en demic rates of PNS S. pneumoniae (weak, moderate). Not recommended  Macrolides: high rates of resistance S. pneumoniae (30%) (strong, moderate) IDSA Guideline for ABRS: CID.March 20, 2012
    47. 47. VIII. Which ATB Recommended for ABRSin 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/cefpodoxime): non–type I hypersensitivity CID.March 20, 2012 IDSA Guideline for ABRS: to penicillin
    48. 48. IX: Should Coverage for S. aureus BeProvided Routinely during Initial Empiric ATBof ABR?  S. aureus (including MRSA) is one of potential pathogen in ABRS  Routine ATB coverage for S. aureus or MRSA during initial empiric therapy of ABRS is not r ecommended (stro ng, moderate). IDSA Guideline for ABRS: CID.March 20, 2012
    49. 49. X: Should empiric ATB be administeredfor 5–7 d vs 10–14 d?  Uncomplicated ABRS in adults: 5–7 days (weak, low-moderate).  Children with ABRS: 10–14 days (weak, low moderate). IDSA Guideline for ABRS: CID.March 20, 2012
    50. 50. XIV: How Long Should Initial Empiric ATB inAbsence of Clinical Improvement Be Continued Before Considering Alternative Management?  Alternative management strategy is recommended if symptoms worsen after 48– 72 hrs of initial empiric ATB or fail to improve despite 3–5 d of initial empiric ATB  (strong, moderate) IDSA Guideline for ABRS: CID.March 20, 2012
    51. 51. XV: What Is Recommended in Who Worsen Despite 72 Hror Fail to Improve After 3–5 D of Initial Empiric ATB?  Should be evaluated for possibility of resistant pathogens, noninfectious etiology, structural abnormality, or other causes for tre atment failure  (strong, low). IDSA Guideline for ABRS: CID.March 20, 2012
    52. 52. INS in ARS EPOS March 2012
    53. 53. INS & ATB in ARS EPOS March 2012
    54. 54. INS VS placebo for adults/children with ABS IDSA Guideline for ABRS: CID.March 20, 2012
    55. 55. XII: Are INS Recommended asAdjunct to ATB in ABR? INS recommended as adjunct to ATB, primarily in patients with history of AR (weak, moderate) IDSA Guideline for ABRS: CID.March 20, 2012
    56. 56. Oral corticosteroids adjuncttherapy Cochrane analysis suggests that oral steroids as adjunctive therapy to oral antibiotics are e ffective for short-term relief of symptoms (he adache, facial pain, nasal decongestion and) i n ARS Evidence level Ia EPOS March 2012
    57. 57. Oral antihistamines No indication for use of AH(both intranasal and oral) in treatment of post viral ARS, except in co-existing allergic rhinitis. EPOS March 2012
    58. 58. Nasal decongestants 27 trials (5,117 participants) of RCT: effectiveness of common cold treatments AH, analgesic-decongestant combinations have some general benefit in adults and older children (recommendation A). Weighed benefits against risk of adverse effects. EPOS March 2012
    59. 59. XIII: Should Topical or Oral Decongestants orAH Be Used as Adjunctive Tx in ABR?  Neither topical nor oral decongestants and/or AH recommended as adjunctive treatment in patients with ABRS (strong, low-moderate). IDSA Guideline for ABRS: CID.March 20, 2012
    60. 60. Nasal or antral irrigation Nasal douching with saline solution has limited effect in adults with ARS (lev el of evidence Ia). Effective in children with ARS in addition to standard medication (level of evidence Ib) an d can prevent recurrent infections (level of evidence IIb) EPOS March 2012
    61. 61. XI: Is Saline Irrigation of Benefit asAdjunctive Tx in ABR? Intranasal saline irrigation(physiologic / hypertonic saline) recommended as an adjun ctive treatment in adults with ABRS (weak, lo w-moderate). IDSA Guideline for ABRS: CID.March 20, 2012
    62. 62. Heated, humidified air Steam may help congested mucus drain better and heat may destroy cold virus as it d oes in vitro. Steam inhalation has not shown any consistent benefits in treatment of common cold, hence is not recommended in routine tr eatment of common cold symptoms EPOS March 2012
    63. 63. Interventions to interrupt spreadof viruses in viral rhinosinusitis  Handwashing, esp around younger children.  Incremental effect of adding antiseptics to normal handwashing to decrease respiratory disease remains uncertain.  Barriers to transmission, isolation, hygienic measures are effective at containing RS virus epidemics. EPOS March 2012
    64. 64. Ipratropium bromide Likely to be effective in ameliorating rhinorrhoea. Recommendation A EPOS March 2012
    65. 65. Probiotics Probiotics were better than placebo in reducing number of acute URTIs, rate ratio of and reducing antibiotic use Recommendation A EPOS March 2012
    66. 66. Vaccination No direct effect in treatment of ARS. Affected frequency and bacteriology of AOM and ABS Causative pathogens of ABS in children in 5 y after introduction vaccination PCV7 as compared to previous 5 y. Proportion of S. pneumoniae declined by 18%, H.influenza EPOS March 2012
    67. 67. NSAID’s, Aspirin oracetominophen NSAID did not significantly reduce TSS, or duration of colds. Outcomes related to analgesic effects of NSAID (headache, ear pain, muscle, jt pain). No evidence of increased frequency of adverse effects in NSAID tx groups. EPOS March 2012
    68. 68. Zinc Zinc would shorten duration of episode of common cold and prevention risk of developi ng episode of common cold. Too early to give general recommendations for use of zinc because not sufficient knowle dge optimal dose, formulation and duration o f treatment EPOS March 2012
    69. 69. Algorithm for management of ABSIDSA Guideline for ABRS: CID.March 20, 2012
    70. 70. EPOS2007EPOS March 2012
    71. 71. Treatment adult with ARS EPOS2007
    72. 72. EPOS2007EPOS March 2012
    73. 73. EPOS March 2012
    74. 74. Treatment children with ARS EPOS 2007
    75. 75. ATB for ARS in children EPOS March 2012
    76. 76. Ancillary therapy for ARS inchildren EPOS March 2012
    77. 77. 40-50MKD 80-90MKD
    78. 78. THANK YOU
    79. 79. Indications for Referral toSpecialist IDSA Guideline for ABRS: CID.March 20, 2012