'Watchful waiting' an option in acute bacterial sinusitis: guideline update

NEW YORK - For adults with acute bacterial sinusitis, watchful waiting to see if the patient can fight the infection on their own is an option, even for "sicker" patients, says an updated evidence-based guideline on adult sinusitis released today.

"Intuitively clinicians often feel that sicker patients benefit more from antibiotics, but our recommendation is that watchful waiting or antibiotics are both appropriate. This empowers patients and clinicians to use antibiotic judiciously, reserving antibiotics for cases that get worse or don't improve over time," Dr. Richard M. Rosenfeld, who chaired both the 2007 guideline and the 2015 update, said in a statement.

The new recommendations, from the American Academy of Otolaryngology--Head and Neck Surgery Foundation, were published online April 1 in Otolaryngology-Head and Neck Surgery.

Sinusitis affects about one in eight adults in the United States resulting in more than 30 million annual diagnoses at a cost topping $11 billion per year. More than one in five antibiotics prescribed in adults are for sinusitis, making it the fifth most common diagnosis responsible for antibiotics.

"The guideline emphasizes the empowerment of patients in self-diagnosing acute sinusitis and contributing to their management; that is up-front and center," Dr. Rosenfeld noted in an interview with Reuters Health.

"It's also very empowering to primary care physicians to know you don't need some sophisticated test to make a diagnosis of acute bacterial sinusitis; you can do it over the phone and the patient can do it themselves. You don't have to look for pus in the nose and conversely just because you do see a lot of pus in the nose does not mean its bacterial and it doesn't mean it needs antibiotic," Dr. Rosenfeld said.

The guideline recommends that clinicians distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute sinusitis caused by viral infections and noninfectious conditions. The clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis (purulent nasal drainage plus nasal obstruction, facial pain-pressure-fullness, or both) persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening).

The guideline advises against radiographic imaging for patients who meet criteria for acute sinusitis, unless a complication or alternative diagnosis is suspected.

For adults with uncomplicated ABRS, clinicians should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy, the guideline says.

Dr. Rosenfeld told Reuters Health 'watch and wait' was a new concept introduced in the 2007 guideline. "We said that even after you've been diagnosed with a probable bacterial sinusitis you can still wait and see how you do. That was sort of heresy back in 2007," he said. "We have upped the ante now by saying it's not just an option but we really recommend that observation is a very appropriate thing to do, we've given a little clearer way of diagnosing bacterial sinusitis, and we've said it's not just for mild illness, but even if you are really sick, there is not any evidence that antibiotics help you more."

If the patient fails to improve with the initial management option by seven days after diagnosis, or worsens during the initial management, the guideline advises reassessing the patient to confirm ABRS, exclude other causes of illness, and detect complications. If ABRS is confirmed in the patient initially managed with observation, the clinician should begin antibiotic therapy. If the patient was initially managed with an antibiotic, the clinician should change the antibiotic, it says.

If an antibiotic is prescribed to treat ABRS, the guideline recommends amoxicillin with or without clavulanate as first-line therapy for five to 10 days for most adults.

Clinicians may also recommend analgesics, topical intranasal steroids and/or nasal saline wash for symptomatic relief of viral, bacterial or chronic sinusitis.

Nasal saline rinse is "incredibly useful for acute and chronic sinusitis, which is also covered in the guideline," Dr. Rosenfeld told Reuters Health. "It thins mucus, gets rid of the germs, reduces inflammation, promotes better functioning and clearance of the sinuses and its cheap and easy to do. Whether it's a viral, bacterial, or chronic sinusitis, nasal saline has a lot of use and we do recommend it."

The U.S. Food and Drug Administration warns against using untreated tap water for nasal rinsing. Instead, to avoid infections, the agency recommends using distilled or sterile water, boiled and cooled tap water, or water passed through a filter with an absolute pore size of 1 micron or smaller.

SOURCE: http://bit.ly/1PgK6L8

Otolaryngol Head Neck Surg 2015.

References: Reuters Health
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