Understanding the New UH Clinical Pathway for Sinusitis

October 4, 2017

New guideline provides advice on watchful waiting, antibiotic use

UH Clinical Update - October 2017

In the adult population, approximately 90 percent of sinus infections, or acute rhinosinusitis, are caused by viruses. But it isn’t uncommon for those viral infections to be improperly treated with antibiotics. It doesn’t help the patient, but it does contribute to the serious and growing problem of antibiotic resistance. 
Brian D'Anza, MD, MA

University Hospitals sinus and rhinology specialist Brian D’Anza, MD, MA, says some 30 million patients are diagnosed with acute bacterial rhinosinusitis (ABRS) each year. More than one in five of all antibiotic prescriptions in the United States are for ABRS. Some of these patients are inadvertently prescribed antibiotics for viral sinusitis, making it the fifth most common reason for antibiotic prescription and contributing to antibiotic resistance. 

“We have been surprised at how many cases of this we’ve seen – some 5,000 diagnoses a month across all UH facilities, which is significant,” says Dr. D’Anza. “We are using this data to improve patient outcomes.”

That is why a new clinical pathway for sinusitis has been developed by Dr. D’Anza and a team of UH otolaryngologists. As he explains, “We want to address antibiotic stewardship, so that antibiotics are prescribed appropriately – and that would be when patients meet the criteria for an acute bacterial sinusitis infection.”

Bacterial sinusitis does often begin with a viral upper respiratory tract infection, and it has symptoms similar to a viral URI, says Dr. D’Anza. It takes time to diagnose a bacterial infection - about 10 days or so. Yet many patients come in to see a physician after only a few days with symptoms.

To help a physician differentiate between the two types of sinusitis, a patient should meet both of the following criteria to be diagnosed with bacterial sinusitis, says Dr. D’Anza.

One, the patient will have a purulent nasal discharge that is accompanied by nasal obstruction, facial pain pressure, or both. And two, this condition must persist for 10 days beyond the onset of the symptoms, or worsen within 10 days after some initial improvement.

“We call this watchful-waiting,” says Dr. D’Anza. During that time, there are other treatments that may be used to control the patient’s symptoms. Nasal irrigation may be helpful, as would intranasal corticosteroids, especially for patients who have a history of chronic allergic rhinitis. Mucolytics (such as Mucinex) can also help with short-term symptoms. However, decongestants, cough medicine and antihistamines are NOT recommended.

In the case of patients who are determined to have bacterial sinusitis, the new care pathway also delineates which antibiotics should be used.

“The existing care guide was 10 years old, and it needed to be to be revised – because choosing the right antibiotic is crucial,” says Dr. D’Anza. The once oft-prescribed azithromycin (Z-Pak), for example, provides suboptimal coverage for sinusitis pathogens.

If patient symptoms persist or worsen after one round of antibiotics, he or she should return for a re-evaluation, he notes.

“In that case, it is best to re-evaluate the diagnosis and consider switching to another class of antibiotic,” says Dr. D’Anza.

If two recommended courses of antibiotics fail, a referral to an otolaryngologist is called for.

Also, CT imaging is generally not necessary and should not be used for uncomplicated bacterial sinusitis. Before ordering a CT scan, a physician should refer the patient to an otolaryngologist for further treatment.

Dr. D’Anza may be reached at 216-844-5037 or at Brian.D’Anza@UHhospitals.org

Upload the UH Quality Care Network Clinical Care Guidelines - Adult Acute Bacterial Rhinosinusitis (ABRS) Outpatient

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