Pharmacologic and Nonpharmacologic therapeutic choices of sinusitis. in a simplified way..

1. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Sinusitis
Anas Bahnassi PhD
Pharmacotherapy of Infectious Diseases
Anas Bahnassi 2014
A Case-Based Approach

2. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Introduction
•Sinusitis:
–An inflammation and/or mucosal thickening of one or more of the paranasal sinus cavity.
Anas Bahnassi 2014
•Causes:
–Allergic, bacterial, viral, or rarely… fungal.

3. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Introduction
•What is Sinusitis ?
Tiny, hair-like structures called cilia help move mucus across sinus membranes and toward an exit. All of sinus cavities connect to the nose to allow a free exchange of air and mucus. Infections or allergies make sinus tissues inflamed, red, and swollen. That's called sinusitis.
Anas Bahnassi 2014

4. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Introduction
•Types of sinusitis:
–Acute Sinusitis:
•Lasts for 4 weeks or less.
–Recurrent Sinusitis:
•Four or more episodes of acute sinusitis in one year each lasting for at least 10 days with an absence of symptoms between episodes.
–Chronic Sinusitis:
•Infections lasting >12 wks with or without treatment.
Anas Bahnassi 2014

5. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Goals of Therapy
•Optimize the symptomatic management of sinusitis, especially drainage of congested sinuses.
•Eradicate infection.
•Prevent recurrences and complications.
•Reduce antibiotic use in ill-defined URTI to avoid the development of antibiotic resistance.
Anas Bahnassi 2014

6. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Investigations:
•The diagnosis of acute bacterial sinusitis relies on history and PI.
•Differentiation of bacterial sinusitis and viral viral URTI is determined by the duration and severity of the symptoms.
Anas Bahnassi 2014

7. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Investigations:
•Symptoms:
–Adults: Persistent symptoms of URTI without improvement after 10-14 days, or worsening after 5 days, with nasal congestion/purulent nasal discharge, and facial pain, with or without fever, maxillary toothpaste or facial swelling.
•Nonspecific concurrent symptoms include: headache, halitosis, hyposmia/anosmia, ear pain/pressure, fatigue and cough.
Anas Bahnassi 2014
Halitosis: bad breath
Hyposmia: reduced ability to smell and detect odours.
Anosmia: inability to perceive odours.

8. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Investigations:
•Symptoms:
–Children: similar to adults but also include: irritability, lethargy, prolonged cough and vomiting in association with gagging on mucus.
–Chronic: purulent nasal discharge, postnasal drip and nasal obstruction accompanied by facial pain.
Anas Bahnassi 2014

9. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Investigations:
•Physical Examination:
–Swelling and/or erythma over the symptomatic area, tenderness on palpation/percussion of paranasal sinuses, periorbital swelling, erythma/swelling of nasal mucosa, postnasal drip.
–Assess patients for changes in extraocular movements, and visual acuity to look for orbital complications.
–Look for associated dental infection by checking the maxillary teeth for tenderness.
Anas Bahnassi 2014

10. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Investigations:
•Objective measurements:
–Transillumination of the sinuses has limited value in adults and no value in children as findings are not specific for bacterial infections. (in children the sinuses are not fully formed yet).
–Nasal cultures are not recommended due to poor correlation with pathogens.
–Plain sinus x-ray and CT-scan are not routinely recommended for diagnosis, as they can distinguish between sinus abnormalities related to viral URTI and bacterial sinusitis.
–MRI not routinely recommended due to poor bone definition.
–CT scans maybe helpful for
Anas Bahnassi 2014

11. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Investigations:
•Objective measurements:
–CT scans maybe helpful for:
•Complications of acute sinusitis (e.g. periorbital edema, subperiosteal abscess).
•Chronic sinusitis not responsive to treatment.
•Chronic progressive nasal obstruction without identified cause.
•Severe presentations where diagnosis is suspected but not clear.
•Patients in whom surgery is considered.
Anas Bahnassi 2014

12. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Investigations:
•Objective measurements:
–Consider underlying risk factors especially in recurrent and/or chronic sinusitis:
•GERD.
•Allergic rhinitis.
•Structural abnormalities.
•Cystic fibrosis (Polyps).
•Immunodeficiency.
•Eosinophilic non-allergic rhinitis.
Anas Bahnassi 2014

13. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Therapeutic Choices: Prevention of Sinusitis
•Limit the spread of viral infection (handwashing).
•Avoid tobacco exposure.
•Reduce environmental allergen exposure.
Anas Bahnassi 2014

14. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Therapeutic Choices: Nonpharmacologic
•Steam inhalation.
•Although there are no scientific evidence, the following maybe helpful:
–Adequate rest and hydration.
–Warm facial packs.
–Sleeping with elevated head.
–Adding pine oil or methanol to steam preparations.
Anas Bahnassi 2014

15. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Therapeutic Choices: Nonpharmacologic
•Surgical drainage for chronic sinusitis may be necessary when patient is not responsive to medical therapy.
Anas Bahnassi 2014

16. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Therapeutic Choices: Pharmacologic
•Principle of sinusitis therapy:
–Preferred treatment is to use analgesic/antipyretic and decongestants when needed.
–70% of cases of acute sinusitis will be resolved without an antibiotic.
–Use antibiotics when symptoms last for over 10 days.
Anas Bahnassi 2014

17. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Therapeutic Choices: Pharmacologic
•Symptomatic Management:
–APAP and/or Ibuprofen can be used to manage pain and/or fever.
–Nasal and oral decongestants maybe beneficial in acute & chronic sinusitis.
–Use oral decongestants with caution in patients with uncontrolled HTN, CVD, hyperthyroidism, DM, angle- closure glaucoma, urinary retention or concurrent use of MAOI.
–Topical decongestants should be used with caution (use of > 3-5 times/day may cause medicamentosa)
Anas Bahnassi 2014
Medicamentosa: rebound congestion

18. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Therapeutic Choices: Pharmacologic
•Symptomatic Management:
–Nasal and oral decongestants are not recommended for patients < 12 years old.
–The use of cough and cold preps. (especially pseudoephedrine) has results in the death of several children.
–Avoid antihistamines in acute sinusitis, because of tendency to cause dryness, and thickening of secretion and crusting.
–2nd gen. antihistamines may have a role in chronic sinusitis, where a clear allergic component is demonstrated.
Anas Bahnassi 2014

19. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Therapeutic Choices: Pharmacologic
•Symptomatic Management:
–The use of nasal corticosteroids in acute sinusitis is controversial.
•They may provide some benefits to patients with recurrent and/or allergic rhinosinusitis,
•They may help in chronic sinusitis due to ability to decrease nasal edema and inflammation promoting drainage.
–No evidence of any use of mucolytics such as guaifenesin
Anas Bahnassi 2014

20. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Therapeutic Choices: Pharmacologic
•Antibiotic Therapy:
–Amoxicillin is the Drug of Choice due to the following reasons:
•Adequate coverage of pathogens involved in acute sinusitis.
•Best activity of all oral β-lactam antibiotics agains S.pneumoniae.
•No other antibiotic is proven superior to amoxicillin.
•Lower potential to induce resistance.
•Relatively few ADRs.
•Relatively inexpensive.
Anas Bahnassi 2014

21. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Therapeutic Choices: Pharmacologic
•Failure of First Line Therapy:
–Amox/Clav is the most appropriate when treatment with Amoxicillin alone fails.
–Antibiotic use within the previous 3 months (esp. macrolides or fluroquinolones) maybe a risk factor for MDR of S.pneumoniae.
–If this the case use different kind of antibiotics.
Anas Bahnassi 2014

22. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Therapeutic Choices: Pharmacologic
•Duration of Therapy:
–Duration of antibiotic therapy to acute sinusitis is not well defined.
–Empirically, 10-14 days.
–Some clinicians continue therapy until patient is symptoms-free, and then for additional 7 days to ensure eradication and avoid relapse.
Anas Bahnassi 2014

23. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Antibiotic Not to be used in for acute sinusitis empirical therapy.
Anas Bahnassi 2014
Antibiotic
Comments
Cephalexin
Poor activity against penicillin intermediate/resistant S.pneumoniae.
No activity against Haemophilus or Moraxella.
Cefaclor
Poor activity against penicillin intermediate/resistant S.pneumoniae.
Marginal activity against Haemophilus .
Cefixime
Poor activity against penicillin intermediate/resistant S.pneumoniae.
Excellent activity against Haemophilus .
Ceftriaxone
Routine use is not recommended in acute sinusitis due to resistance.
Option for severe acute sinusitis with failed therapy.
Single dose not effective in eradication of S.pneumoniae.
3 days of IV/IM therapy is recommended.
Clindamycin
Not recommended in acute sinusitis, No activity against Haemophilus or Moraxella.
Maybe used as an alternative to Amox/Clav in chronic sinusitis.
Erythromycin
Poor activity against Haemophilus or Moraxella. Possible resistance.
Ciprofloxacin
Suboptimal coverage of S.pneumoniae.

24. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Recommended Empirical Therapy of Bacterial Sinusitis in Children
Infection
Recommended Therapy
Comments
Acute Sinusitis
SD Amox X 10 days HD Amox X 10 days
Allergy?: SMX/TMP X10 d
Refer to specialist if ≥ 4 episodes/yr.
HD Amox should be used in children with high risk of antibiotic resistance.
SMX/TMP resistance is increasing, if suspected use Macrolides.
Failure of first line therapy
Amox/Clav X 10 days + Amox X 10 days, or
Cefuroxime X 10 days.
Allergy?: Azithromycine X3-5 days or Clarithromycin X 10 days.
Severe Presentation: IV Cefuroxime X 10 days
If Cefuroxime tablets or suspension not tolerated consider: Cefprozil (Better palatability )
Azithromycin and Clarithromycin use should be restricted.
Anas Bahnassi 2014

25. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Recommended Empirical Therapy of Bacterial Sinusitis in Children
Infection
Recommended Therapy
Comments
Chronic Sinusitis
Amox/Clav X 3 weeks.
Allergy?: Clindamycin X 3 weeks.
Longer therapy might be recommended in special circumstances.
Anas Bahnassi 2014

26. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Recommended Empirical Therapy of Bacterial Sinusitis in Adults
Infection
Recommended Therapy
Comments
Acute Sinusitis
SD Amox X 10 days HD Amox X 10 days
Allergy?: SMX/TMP X10 d
Refer to specialist if ≥ 4 episodes/yr.
Advice patients that symptoms may last up to 10 d
SMX/TMP resistance is increasing, if suspected use Macrolides.
Failure of first line therapy
Amox/Clav X 10 days + Amox X 10 days, or
Cefuroxime X 10 days.
Allergy?: Azithromycine X3-5 days or Clarithromycin X 10 days or Levofloxacin 5-10 days or Moxifloxacin 5-10 days.
Macrolides and Fluroquinolones use should be restricted.
Anas Bahnassi 2014

27. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Recommended Empirical Therapy of Bacterial Sinusitis in Adults
Infection
Recommended Therapy
Comments
Chronic Sinusitis
Amox/Clav X 3 weeks.
Allergy?: Clindamycin X 3 weeks.
Repeated courses of antibiotics are not recommended.
Anas Bahnassi 2014

28. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Therapeutic Tips:
•If patient shows no improvement after 72 hrs of symptomatic + 1st line therapy move to 2nd line therapy.
•Inform patients that complete recovery of symptoms may take up to 14 days.
•If patient deteriorates assess for complications.
•Routine follow-up for asymptomatic patients is not required.
•If patient received an antibiotic within the last 3 months choose an antibiotic from a different class.
•Presence of tenacious, thick, brown nasal secretion may heighten the suspicion of fungal infection.
Anas Bahnassi 2014

29. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Refer to specialist if:
•Fails 2nd line therapy.
•Chronic sinusitis not responding to medical therapy.
•Anatomic anomalies
•Develops complications.
Anas Bahnassi 2014

30. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Pharmacotherapy: Infectious Diseases: Anas Bahnassi PhD
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Anas Bahnassi 2014