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Tuesday, February 7, 2017

Still No Consensus on Antibiotics for Persistent Sinus Infection


When it comes to patients with recurrent but otherwise uncomplicated sinusitis, clinicians still don't agree on whether antibiotics are an appropriate treatment, a "grand rounds discussion" in Annals of Internal Medicine indicated.

Two clinicians from Boston's Beth Israel Deaconess Medical Center offered differing opinions on prescribing antibiotics for a hypothetical "Mr. X," an older man with worsening nasal discharge over several weeks and a history of previous episodes.

While Diane Brockmeyer, MD, concluded that the patient's persistent symptoms and clear preference for antibiotics were sufficient grounds for prescribing them, Howard Gold, MD, said they weren't warranted yet -- arguing that a more conservative approach may help the patient get better without the risk for adverse reactions.

The article began with a review of Mr. X's case and included a statement of his symptoms and history in his (hypothetical) voice.

"The way that I distinguish an allergic sinusitis from a bacterial sinusitis is that when I have an allergic sinusitis, the symptoms improve within about a week to 10 days, but with a bacterial sinusitis I get physically weak and can't even get out of bed," the statement said.

"When I go to a visit, I generally do not say, 'I want an antibiotic.' The doctor will ask me, 'Why are you here, and tell me about what is going on,' and I have found that, after reviewing my history, she ends up saying, 'I think you may need an antibiotic,'" Mr. X concluded.

In the review, Brockmeyer found that Mr. X presented signs and symptoms that suggested bacterial sinusitis, including mucopurulent nasal drainage, worsening after 10 days of mild symptoms, unilateral maxillary pain, fever, and unilateral sinus tenderness. Because of an allergy to penicillin, she recommended treatment with doxycycline, 100 mg, orally twice a day for 5 to 7 days.

She stressed the importance of patient preference and shared decision making, stating that "when in line with clinical guidelines and reasonable medical practice as is the case here, [it] should factor into the decision-making process."

"There is some evidence that shared decision making can improve patient satisfaction, improve patient medical knowledge, and decrease a sense of conflict with the physician. In addition, there is evidence that shared decision making significantly reduces antibiotic prescribing for acute respiratory infections in primary care without a decrease in patient satisfaction or repeated consultations for the same illness," she wrote online.

Conversely, Gold refrained from recommending antibiotics -- instead asking Mr. X to monitor his temperature and symptoms and maximize other therapeutic approaches, such as nasal steroids and saline nasal lavage.

He noted that he would consider antibiotics in the future depending on Mr. X's clinical course, particularly in case of escalation of fever, facial pain or swelling, or lack of improvement with other more conservative methods.

Ironically, although Gold is medical director of antibiotic stewardship at Beth Israel Deaconess's Silverman Institute for Health Care Quality and Safety, he didn't mention public health considerations as a reason to avoid antibiotics for Mr. X.

"I would delve into the patient's history a bit more, particularly with regard to prior episodes that were diagnosed as bacterial sinusitis, documentation of prior episodes of pneumonia, and his allergic reaction to ampicillin. Microbiological data and vaccination history would also be of interest, because this information may point to potentially useful preventive measures and/or clues to an immunodeficiency state. Use of intranasal steroids is appropriate for allergic rhinosinusitis, but because of the delayed effect of steroids, waiting until symptoms are 'bad' probably undermines their effectiveness," he stated.

Neither Brockmeyer nor Gold recommended further diagnostic evaluation,such as use of serum inflammatory markers (ESR, CRP) or radiologic imaging of the sinuses.

In introducing the case, Howard Libman, MD, also of Beth Israel Deaconess, noted a recently issued recommendation from the American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC) on appropriate use of antibiotics for acute respiratory tract infections. Those recommendations called on clinicians to reserve antibiotic treatment for acute rhinosinusitis in patients with persistent symptoms for more than 10 days, high fever and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or worsening symptoms after a typical viral illness that lasted 5 days and had initially improved ("double-sickening"). Mr. X did not quite meet those criteria, lacking the high fever.

Treating acute sinusitis with antibiotic therapy can be associated with risks, ranging from minor side effects -- such as rash, self-limited diarrhea, decreased appetite, dyspepsia, and vaginal yeast infection -- to major problems, including anaphylaxis and Stevens-Johnson syndrome.

Bryan Kraft, MD, a pulmonologist at Duke University, told MedPage Today that it can be difficult to distinguish bacterial from viral or allergic sinusitis.

"The grey area are exactly those patients like Mr. X who have had low grade fever, bothersome asymmetrical maxillary pain, purulent nasal discharge, etc. but are without alarming signs or symptoms of severe bacterial infection (e.g. high fevers, worsening symptoms, etc.) as stated by the guidelines," he wrote to MedPage Today.

Kraft commented that both Brockmeyer and Gold offered valuable insight: "I agree with Dr. Brockmeyer's use of shared decision making to help determine best treatment plan for the individual patient, and I also agree with Dr. Gold's emphasis on delving deeper into the medical history and his emphasis on educating patients about indications for antibiotics. He is absolutely correct that all too often 'associations' get taken by patients as 'cause and effect.'"

For Kraft, the case also invited the larger question of individual patient characteristics:

"I would also emphasize that individual patient characteristics need to be taken into consideration when determining how to treat patients in the grey area, e.g., any anatomical abnormalities that prevent ostia from draining regardless of the above non-antibiotic measures, or whether the patient is taking immune-suppressing medications (increasingly common these days), or has poorly-controlled diabetes (also a form of immune suppression).

"If present, these would probably make me more likely to treat with antibiotics if I thought acute bacterial sinusitis was possible (so would maximize sensitivity)."