Year 2004 ATBS (Antibiotic Therapy for Bacterial Sinusitis) Clinical Consensus Panel Report® and Treatment Recommendations, Part I
Author: Gideon Bosker, MD, Assistant Clinical Professor, Section of Emergency Services, Yale University School of Medicine; Editor-in-Chief, Clinical Consensus Reports®, writing on behalf of the ATBS Clinical Consensus Panel.
Peer Reviewers: Theodore C. Chan, MD, FACEP, FAAEM, Associate Professor of Clinical Medicine, University of California, San Diego; Stephen A. Crabtree, DO, Assistant Professor, Department of Emergency Medicine, Medical College of Georgia, Augusta.
Approximately 20 million cases of acute bacterial rhinosinusitis (ABRS) are managed annually in the United States. According to National Ambulatory Medical Care Survey (NAMCS) data, sinusitis is the fifth most common diagnosis for which an antibiotic is prescribed, and it accounted for 7-12% of all antibiotic prescriptions written from 1992 to 1999. In 1996, the primary diagnosis of sinusitis led to expenditures of approximately $3.39 billion in the United States.1
Given the importance and widespread prevalence of this common outpatient infection, the primary mission statement of the Year 2004 ATBS (Antibiotic Therapy for Bacterial Sinusitis) Clinical Consensus Panel & Scientific Roundtable was to assemble an academically oriented panel of national experts—investigators and clinical scholars in otolaryngology, infectious diseases, primary care medicine, and emergency medicine—to evaluate the current medical literature and national guidelines; and then, to determine their implications for diagnostic assessment and treatment of adult patients with acute bacterial sinusitis.
This article represents the output of this scientific roundtable and outlines, in evidence-based detail, what the ATBS Consensus Panel concluded to be optimal, risk-stratified, empiric treatment recommendations for this patient population. In addition, the panel has identified key clinical findings, resistance patterns, risk factors, coexisting conditions, and other clinical triggers supporting referral of patients with ABRS to an otolaryngologist for more complex—i.e., multimodal surgical and more intensive antimicrobial—management strategies.
To generate the evidence-based recommendations presented in this report, ATBS Consensus Panel members reviewed more than 100 published studies, as well as antimicrobial resistance data and consensus guideline documents pertaining to sinusitis issued by otolaryngologists, emergency medicine specialists, and primary care physicians.
Moreover, to ensure that the ATBS Consensus Panel’s recommendations were current, fairly balanced, and consistent with expert opinion and national guidelines, its members consulted and carefully analyzed recommendations and position statements issued by such associations as the American College of Physicians (ACP), the American Academy of Otolaryngology and Head and Neck Surgery (AAOHNS), the Sinus and Allergy Health Partnership, the Centers for Disease Control and Prevention (CDC), and the Infectious Disease Society of America (IDSA).2-4
Endorsed by a multi-disciplinary panel of clinical experts, the Year 2004 ATBS Clinical Consensus Report primarily is directed toward physicians faced with the challenge of managing patients with ABRS in the primary care, emergency, and urgent care settings. The ultimate goal is to provide a concise, practical, and clinically relevant schemata for day-to-day patient management in which evidence can be put into practice to optimize clinical outcomes.—The Editor
(Dr. Bosker served as moderator of the ATBS Consensus Panel. Panel members were Michael Armstrong, MD, Otolaryngologist, Private Practice, Richmond, VA; Elizabeth Blair, MD, Department of Otolaryngology, University of Chicago Hospitals and Medical Center, Chicago, IL; Charles Emerman, MD, FACEP, Professor and Chairman, Department of Emergency Medicine, Case Western Reserve University, Cleveland Clinic Foundation, Cleveland, OH; Daniel Kim, MD, FACS, Chief, Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Massachusetts, Worcester; Steven Mosher, MD, Infectious Diseases, Sharpe Clinic, San Diego, CA; Aphrodite Papadakis, MD, Department of Family Practice and Geriatrics, Metrohealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Isidro Pujol, DO, Department of Internal Medicine, Mt. Sinai Medical Center, Miami, FL; Paul Stander, MD, FACP, Medical Director, Banner Healthcare Systems, Department of Internal Medicine, Arizona Health Science University, Phoenix; and Gregory A. Volturo, MD, FACEP, Vice Chairman and Associate Professor, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester.)
Introduction: Background, Definitions, and Antimicrobial Treatment Issues
Acute bacterial sinusitis is one of the 10 most common diagnoses encountered in ambulatory practice and is the fifth most frequent diagnosis for which an antibiotic is prescribed. Primary care physicians frequently approach sinusitis as the manifestation of acute bacterial infection and prescribe an antibiotic in 85-98% of cases. However, sinusitis frequently is caused by viral infection and often will resolve without antibiotic treatment, even if it is bacterial in origin.1
Acute rhinosinusitis is defined by symptom duration of fewer than four weeks. Acute bacterial sinusitis usually is a secondary infection resulting from sinus ostia obstruction, impaired mucus clearance mechanisms caused by an acute viral upper respiratory tract infection, or both. According to epidemiological estimates, only 0.2-2% of viral upper respiratory tract infections in adults are complicated by bacterial rhinosinusitis.1,2,5,6 The accepted standard for the definitive diagnosis of bacterial sinusitis is sinus puncture, with Streptococcus pneumoniae and Haemophilus influenzae bacteria most commonly isolated from infected maxillary sinuses. However, sinus puncture is an invasive procedure seldom performed in the primary care setting; as a result, other criteria must be evaluated as triggers for antimicrobial therapy.
Because no simple and accurate office-based test for acute bacterial sinusitis currently is available, clinicians must rely on clinical findings and historical features to confirm the diagnosis. This may be problematic, since signs and symptoms of acute bacterial sinusitis and those of prolonged viral upper respiratory tract infections are very similar, resulting in frequent misclassification of viral cases.5,6
As expected, the diagnosis and management of acute bacterial sinusitis is a fiercely debated topic, with expert opinion varying as to when antibiotic therapy is appropriate, and which antibiotics should be employed as first-line therapy. A recent set of recommendations published by the ACP concluded that most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections, and that specific clinical triggers should be utilized to initiate antibiotic-centered management.3
Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. In most cases, the clinical diagnosis of ABRS should be reserved for patients with rhinosinusitis symptoms lasting seven days or more who have purulent nasal secretions and maxillary facial or tooth pain or tenderness. Patients who have mild-to-moderate symptoms of rhinosinusitis for fewer than seven days are unlikely to have bacterial infection.
With respect to patient evaluation, sinus radiography is not recommended for diagnosis in routine cases. Moreover, symptomatic treatment and reassurance are the preferred initial management strategy for patients with mild symptoms lasting fewer than seven days. Antibiotic therapy, however, may be considered for patients with severe symptoms who meet the criteria for clinical diagnosis of ABRS, regardless of duration of illness. (See Table 1.)
When the 40-50% prevalence of bacterial rhinosinusitis in patients whose diagnosis is established by signs and symptoms and the modest effectiveness of antibiotic treatment were considered, a cost-effectiveness model sponsored by the Agency for Healthcare Research and Quality favored antibiotic treatment for patients with moderate-to-severe symptoms and symptomatic treatment for those with mild symptoms.1,3,6
Antimicrobial Treatment Issues. There is general agreement that antibiotics should be used only when the clinical history, risk factors, and patient presentation strongly suggest bacterial rhinosinusitis. However, there is no universal consensus as to which antibiotics should be employed as first-line agents for empiric management of patients with ABRS and which antimicrobial classes—or specific agents within those classes—are more appropriately reserved for treating more invasive infections, treatment failures, and/or infections in patients with comorbid or immune-compromising conditions.7,8 Making such distinctions—using clinical trials, expert opinion, resistance patterns, and outcome-sensitive criteria as guideposts—was one of the mandates challenging the ATBS Consensus Panel.
In addition to such widely used agents as amoxicillin-clavulanate, doxycycline, and amoxicillin, the safety and efficacy of macrolides such as azithromycin and clarithromycin, as well as the respiratory fluoroquinolones moxifloxacin, levofloxacin, and gatifloxacin have been studied in patients with acute bacterial sinusitis.
The antibiotic selection decision can be complicated in real world practice, where medication compliance, duration of therapy, and patient convenience parameters frequently are factored into the drug selection equation for acute bacterial sinusitis and other respiratory tract infections. In fact, accumulating evidence published in the peer-reviewed medical literature suggests that short-course (i.e., 1-, 3-, and 5-day courses of azithromycin for acute otitis media [AOM], acute bacterial exacerbations of chronic bronchitis [ABECB] and acute bacterial sinusitis, and community-acquired pneumonia [CAP], respectively) may be as effective as traditional, longer (10- to 14-day) therapeutic courses.2-5,7-10
In acute bacterial sinusitis, most short-course therapy data have been generated for maxillary disease in adult patients. Regimens have included three days of azithromycin or cotrimoxazole (trimethoprim/sulfamethoxazole) or five days of cefpodoxime, telithromycin, gatifloxacin, gemifloxacin, or amoxicillin/clavulanic acid.11-22 The ATBS Consensus Panel reviewed recent studies showing comparable clinical success rates for a three-day course of azithromycin and standard regimens of amoxicillin/clavulanate.23 One study, in particular, has shown that three days of azithromycin (500 mg PO QD) was as effective as 10 days of amoxicillin/clavulanate (500 mg PO TID) in subjects with acute bacterial sinusitis, and that a statistically significant higher percentage of subjects completed therapy in the three-day azithromycin arm compared with the amoxicillin/clavulanate arm.23
The potential clinical implications of such studies were evaluated by the ATBS Consensus Panel and will be discussed in more detail in the sections that follow. In this regard, many experts note that cost containment in antimicrobial therapy and sensitivity to medication compliance and patient satisfaction issues should prompt consideration of short-course therapy for the management of common bacterial respiratory tract infections, including acute bacterial sinusitis. Against the backdrop of such evidence, recent approval of a short-course (three days) regimen for acute sinusitis, and patient preference for convenient dosing, the ATBS Consensus Panel was asked to evaluate the possible role and appropriateness of short-course regimens for this condition.
Epidemiological Patterns and Drug Resistance. The ATBS Consensus Panel also noted that important changes have been occurring in the epidemiology and resistance patterns for antibiotics used as first-line therapy in patients with acute bacterial sinusitis. In particular, there is growing concern about the development of monoclonal resistance among S. pneumoniae species to advanced generation fluoroquinolones, especially levofloxacin.24-27 A recent IDSA report echoes many of the cautionary statements about inappropriate use of respiratory fluoroquinolones issued by the CDC Drug-Resistant Streptococcus pneumoniae Working Group (CDC-DRSPWG).28,29
Moreover, a number of surveillance reports have been published noting treatment failures with advanced fluoroquinolones, and recent epidemiological studies presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) have revealed S. pneumoniae resistance rates to levofloxacin as high as 4.2% in states such as Massachusetts.30 Because of these concerns, the CDC-DRSPWG has issued recommendations urging caution against overuse of this class of antibiotics as initial empiric therapy, except in selected patient subgroups. The IDSA Practice Update Guidelines noted explicit support for this drug selection strategy in patients with CAP; accordingly, the implications of overuse of advanced fluoroquinolones and their role as initial agents for ABRS will be discussed.2,7-9,31-33
Summary. The aforementioned issues are of great interest to a wide range of emergency medicine; primary care; and ear, nose, and throat (ENT) practitioners. Consequently, it is important that clinical scholars and thought leaders generate clear, concise, and evidence-based analyses and recommendations for this commonly encountered clinical problem.
With these considerations in clear focus, the purpose of the ATBS Consensus Panel treatment guidelines is to provide evidence-based, expert-endorsed recommendations for the diagnosis and outcome-effective treatment of ABRS. To achieve its goal, the panel considered a number of clinical issues linked to diagnosis, referral strategies, and treatment options in patients with ABRS. (See Table 2.) It is their view that adherence to these guidelines will foster appropriate and effective antibiotic use, promote rational use of radiological resources for patient evaluation, suggest strategies for distinguishing between self-limited viral rhinosinusitis and bacterial infection, and identify those patients requiring prompt referral to an otolaryngologist.
Definition and Differential Diagnosis of ABRS
ABRS most often is preceded by a viral upper respiratory tract infection (URI). Allergy, trauma, dental infection, or other factors that lead to inflammation of the nose and paranasal sinuses also may predispose individuals to ABRS. (See Table 3.) Patients with a "common cold" (viral URI) usually report some combination of the following symptoms: sneezing, rhinorrhea, nasal congestion, hyposmia/anosmia, facial pressure, postnasal drip, sore throat, cough, ear fullness, fever, and myalgia. A change in the color or the characteristic of the nasal discharge is not a specific sign of a bacterial infection. Bacterial superinfection may occur at any time during the course of a viral URI.
Most experts agree that while no historical features are perfectly predictive of bacterial involvement, from a practical—and differentiating—clinical perspective, the risk that bacterial superinfection has occurred is increased if the illness has not resolved after seven days.6,34,35 In general, then, a diagnosis of ABRS may be made in adults or children with symptoms of sinusitis that have not improved after seven days or have worsened after five days. Because individual cases may fall outside the boundaries of this typical range or disease progression pattern strongly suggesting bacterial infection, practicing clinicians should rely on clinical judgment when applying the principles and guidelines contained in this consensus report.
ABRS may be accompanied by some or all of the following symptoms: nasal drainage, nasal congestion, facial pressure/pain (especially when unilateral and focused in the region of a particular sinus), postnasal drainage, hyposmia/anosmia, fever, cough, fatigue, maxillary dental pain, and ear pressure/fullness. (See Table 4.) Physical examination provides limited, definitive information in the diagnosis of ABRS. Plain film radiographs and computed tomography (CT) and magnetic resonance imaging (MRI) scans are not recommended to diagnose uncomplicated cases of ABRS (see discussion in The Challenge of Patient Evaluation).4,36-40
The differential diagnosis of patients with suspected ABRS includes a number of entities, among them: seasonal allergic rhinitis, perennial allergic rhinitis, non-allergic rhinitis with eosinophilia, rhinitis medicamentosa, mechanical or anatomic obstruction, cerebrospinal fluid rhinorrhea, hypothyroidism, Wegener’s granulomatosis, and sinusitis of viral or fungal etiology. (See Table 5.)
Referral Triggers. While primary care and emergency medicine practitioners can manage most cases of ABRS, a small subset of patients may have physical findings, profiles, comorbid conditions, and/or presumed etiologic pathogens that will prompt early referral to an otolaryngologist for more specialized care and evaluation. (See Table 6.) In this regard, patients suspected of having infection with such etiologic agents and Pseudomonas, methicillin-resistant Staphylococcus aureus (MRSA), or fungal organisms should be referred to an otolaryngologist or infectious disease specialist for additional evaluation.
Certain patient subgroups and comorbid conditions also deserve early specialty-focused evaluation, among them: patients with poorly controlled diabetes; immunosuppression; transplant patients; patients with polyposis syndrome; and those with recurrent, acute bacterial sinusitis. Physical findings that would suggest the need for prompt referral include swelling around the eye, facial cellulitis, visual disturbances, asymmetrical findings, periorbital or neurological complications, bony erosion, enlargement of the sinus cavity, and suspicion of a subperiostal abscess. Finally, a lower threshold for early referral and close follow-up also might be prompted by failure of a single course of appropriate therapy, worsening symptoms, or failure to improve within 48-72 hours after appropriate antimicrobial management.
Antibiotic Selection: General Principles and Considerations
The ATBS Consensus Panel concurred that appropriate use of antibiotics requires clinical confirmation of the diagnosis of ABRS based on criteria outlined in this report. (See Table 1.) In this regard, physicians should use clinical judgment when ordering radiographic modalities to evaluate patients with symptoms of rhinosinusitis, with the understanding that such modalities usually are neither required as part of an initial patient assessment nor as a guide to antimicrobial management. (See Table 7.)
For acute bacterial rhinosinusitis, randomized, double-blind, placebo-controlled trials of antibiotic treatment using pretreatment and post-treatment culture of sinus aspirates are limited. Five randomized, double-blind clinical trials with good methods have compared antibiotic treatment with placebo for acute rhinosinusitis in adults.2 Two recent meta-analyses, one under the auspices of the Cochrane Collaboration and the other under contract from the Agency for Healthcare Research and Quality (AHRQ), recently have been published. Both concluded that although antibiotics are statistically more efficacious than placebo for reducing or eliminating symptoms at 10 and 14 days, the effect size (degree of benefit) is relatively small. Moreover, most patients who receive placebo improve without antibiotic therapy.2,4, The AHRQ report pointed out that symptoms improved or resolved in 69% (CI, 57-79%) of patients by 14 days without any antibiotic treatment. When the 40-50% prevalence of bacterial rhinosinusitis in patients whose diagnosis is determined by predictive signs and symptoms and the modest effectiveness of antibiotic treatment were considered, a cost-effectiveness model sponsored by the AHRQ favored antibiotic treatment.3,4,6
Deciphering the strengths, subtleties, and weaknesses of recommendations issued by different authoritative sources can be problematic and confusing for primary care physicians. Because diagnostic approaches, patient disposition practices, and treatment pathways vary among practitioners and institutions—and from region to region—there is a need to develop evidence-based, management guidelines that can be applied to many different practice settings. Unfortunately, no single set of guidelines is applicable to every patient or practice environment; therefore, clinical judgment must prevail. This means taking into account local antibiotic resistance patterns, epidemiological and infection incidence data, and patient demographic features to make antibiotic-related decisions.
In general, the approach to antibiotic therapy in patients with ABRS usually will be empiric, and must account for a number of clinical, epidemiological, and other—sometimes unpredictable—factors related to antibiotic resistance patterns and sinus tract pathogens. As a general rule, appropriate antibiotic choices for the patient with ABRS require consideration of a specific agent that will yield a clinical cure in the patient today, while preventing or diminishing the risk of inducing drug-resistant organisms that will infect the community tomorrow. This concept of sequential selection, in which agents are chosen on the basis of such pharmatectural criteria as the propensity for resistance induction, clinical trial evidence, cost, correct spectrum coverage, daily dose frequency, duration of therapy, side effects, drug interactions, and other outcome-sensitive criteria, has been endorsed by the ATBS Consensus Panel.
Microbiology of ABRS. The most common bacterial isolates recovered from the maxillary sinuses of patients with ABRS are S. pneumoniae, H. influenzae, and Moraxella catarrhalis. Other streptococcal species, anaerobic bacteria, and Staphylococcus aureus are found in a small percentage of cases. The increasing prevalence of penicillin nonsusceptible isolates of S. pneumoniae is a problem in the United States. In 1998, 16.1% and 28.6% of outpatient respiratory isolates were penicillin-intermediate. A review of sinus aspiration studies that have been performed in adults with ABRS showed that S. pneumoniae is isolated in approximately 20-43% of aspirates, H. influenzae in 22-35%, and M. catarrhalis in 2-10%. In children with ABRS, S. pneumoniae is isolated in approximately 35-42%, whereas H. influenzae and M. catarrhalis each are recovered from about 21-28% of aspirates. Streptococcus pyogenes and anaerobes account for 3-7%.41-45 Other bacterial isolates found in patients with ABRS include S. aureus and anaerobes.1-3,7,46,47
Indications for Antibiotic Therapy in ABRS. Because of concerns about inappropriate and/or overuse of antibiotics, the ATBS Consensus Panel articulated specific triggers that support antimicrobial therapy in patients without comorbid conditions who have symptoms consistent with ABRS. (See Table 1.) Generally, in the absence of other compelling factors supporting antimicrobial treatment, initial antibiotic therapy is not recommended for patients with acute, mild-to-moderate symptoms of rhinosinusitis for fewer than seven days duration that are limited to the following: 1) nasal drainage, rhinorrhea, or nasal congestion; 2) malaise in the absence of severe symptoms suggestive of rhinosinusitis; 3) non-specific, non-focal facial pain or pressure; or 4) temperature less than 101°. Patients with the aforementioned symptoms suggestive of rhinosinusitis who are not improving or who are worsening after 2-3 days also may be considered for antibiotic therapy. The presence of comorbid conditions, recurrent rhinosinusitis, and/or an unusual or aggressive course may prompt consideration of early antibiotic therapy.
Even when antibiotics are not employed, a number of management approaches focused on symptom-directed therapy should be considered in the risk-stratified group described above (i.e., fewer than seven days duration of symptoms with no comorbid conditions). Among such interventions, antipyretics, analgesics, topical or systemic decongestants, mucous-thinning agents, and nasal steroids may be considered. (See Table 1 and Table 8.)
Antibiotic therapy strongly should be considered in patients with some or all of the findings in the following severe-category ABRS symptom group, regardless of duration of symptoms. Put another way, even when the following symptoms are present for fewer than seven days, patients should be considered candidates for antibiotic treatment with: 1) temperature higher than 102°; 2) unilateral facial pain or pressure; 3) bilateral facial pain, which may suggest pan-sinusitis; 4) facial erythema; 5) swelling over the sinus; 6) maxillary teeth pain; or 7) bimodal disease course. Stronger consideration for antibiotic therapy also should be given in immunocompromised patients with symptoms of fewer than seven days duration. Clinical judgment should prevail in such cases, and earlier referral to an otolaryngologist may be necessary.
Antibiotic Selection: Overview and General Principles. Based on the current clinical studies and epidemiological data, the principal pathogens that must be covered on an empiric basis in adults with bacterial rhinosinusitis include: S. pneumoniae, H. influenzae, and M. catarrhalis. The 1998 outpatient U.S. prevalence of beta-lactamase-producing isolates of M. catarrhalis was 98%. More than 90% of isolates of M. catarrhalis were resistant to TMP/SMX (trimethoprim/sulfamethoxazole). All the isolates of M. catarrhalis were susceptible to amoxicillin/clavulanate, cefixime, fluoroquinolones, and macrolides/azalides.1-4,48
A smaller percentage of patients will have infection with anaerobic organisms, S. aureus, and other streptococcal species. The ATBS Consensus Panel noted that there may be a "disconnect" (i.e., an incompletely understood and not entirely predictable relationship) between an antibiotic’s minimum inhibitory concentration (MIC) level against a specific organism and its capacity for producing satisfactory clinical outcomes in the real world. This "disconnect" may be explained by the unique qualities of an antimicrobial, such as sinus tissue penetration and/or pharmacokinetics, patient medication compliance, and other incompletely understood factors.
For the most part, clinical trials comparing the safety and efficacy of advanced generation macrolides, respiratory fluoroquinolones (i.e., moxifloxacin, levofloxacin, and gatifloxacin), and beta-lactams (i.e., amoxicillin/clavulanate, cefuroxime, cefpodoxime) have demonstrated generally comparable outcomes in terms of clinical cure and bacteriologic eradication rates in outpatients with acute sinusitis.6,11,12,18-23,49-51 Differences in trial design have made it difficult to draw firm, agent-specific comparisons among available agents. It should be noted, however, that emergence of resistance among S. pneumoniae species to new generation fluoroquinolones has been reported in a number of geographic regions, including the United States, Hong Kong, and Canada; this may have implications for treatment.24-27,31-33
Based on these findings, The CDC-DRSPWG and IDSA have cautioned against overuse of new generation fluoroquinolones in outpatients with CAP. The ATBS Consensus Panel concurs that it is reasonable to extend these concerns to patients with acute sinusitis, while recognizing that a certain, risk-stratified subset of patients (i.e., those with drug-resistant S. pneumoniae [DRSP] infection, gram-negative infection, and previous treatment failure with macrolides and/or beta-lactams) are suitable and appropriate candidates for initial, empiric therapy with respiratory fluoroquinolones.24-27,31-33
The ATBS Consensus Panel evaluated issues and concerns surrounding antibiotic overuse, the potential for inducing drug resistance in the fluoroquinolone class, and the need to identify correct spectrum antibiotics with coverage patterns matching pathogens most likely to be encountered in patients with ABRS. The antibiotic selection process also should account for outcome-sensitive criteria such as cost, daily dose frequency, duration of therapy, side effects, patient tolerability, and drug interactions.
Based on such an aggregate analysis—one that accounts for the multiplicity of factors that go into the drug selection equation—the ATBS Consensus Panel recommends as first-line (preferred) initial, empiric therapy in otherwise healthy adult patients with acute bacterial rhinosinusitis who do not have comorbid conditions, the following agents: azithromycin; amoxicillin/clavulanate; or, when cost considerations predominate, high-dose amoxicillin therapy. (See Table 9.) As alternative first-line therapy, the panel recommends moxifloxacin (the preferred fluoroquinolone) or levofloxacin; other options include clarithromycin, gatifloxacin, or doxycycline. Among the advanced generation fluoroquinolones, moxifloxacin is preferred by the ATBS Consensus Panel as the initial fluoroquinolone of choice in ABRS because it has the most favorable MICs against S. pneumoniae and a more focused spectrum of coverage against gram-positive organisms than levofloxacin or gatifloxacin.52-54
The ATBS Consensus Panel emphasizes that some patients with ABRS present with more severe disease or have comorbid conditions that necessitate more intensive antibiotic therapy. In patients with comorbid conditions or immune system compromise or who are at risk for DRSP or more invasive infection, the panel recommends advanced generation fluoroquinolones such as moxifloxacin and levofloxacin as initial first-line therapy; amoxicillin/clavulanate and other beta-lactams may be considered for alternative first-line therapy. (See Table 10.) In those selected cases in which a sinus puncture has yielded an infecting organism, antibiotic therapy should be pathogen-directed and based on culture sensitivities.
The ATBS Consensus Panel recognizes that, in the final analysis, the choice of an antibiotic in any individual patient with ABRS will depend upon the clinician’s assessment and judgment, local resistance trends, and established institutional or practice pathways that have been developed for this infection. As a result, the treatment guidelines recommended in this report are intended only as a guide; selection strategies that deviate from those recommended by the panel may represent acceptable, safe, and effective approaches to patient management.
1. Young J, Bucher H, Tschudi P, et al. The clinical diagnosis of acute bacterial rhinosinusitis in general practice and its therapeutic consequences. J Clin Epidemiol 2003;56:377-384.
2. Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2000;123(Suppl 1 Pt 2):S5-S31.
3. Snow V, Mottur-Pilson C, Hickner JM, for the American Academy of Family Physicians; American College of Physicians-American Society of Internal Medicine; Centers for Disease Control; Infectious Diseases Society of America. Principles of appropriate antibiotic use for acute sinusitis in adults. Clinical Practice Guideline, Part 1. Ann Intern Med 2001;134:495-497.
4. Benninger MS, Sedory Holzer SE, Lau J. Diagnosis and treatment of uncomplicated acute bacterial rhinosinusitis: Summary of the Agency for Health Care Policy and Research evidence-based report. Otolaryngol Head Neck Surg 2000;122:1-7.
5. Department of Health and Human Services. Centers for Disease Control and Prevention. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 1997. Available online at: www.cdc.gov. Accessed May 1, 2003.
6. Sinus and Allergy Health Partnership, Executive Summary. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2000;123(1 Pt 2):5-31.
7. Karchmer A. Antibacterial therapy. In: Goldman L, Bennett JC, eds. Cecil Textbook of Medicine, 21st ed. Philadelphia: WB Saunders Co; 2000:1591-1603.
8. Blondeau J, Felmingham D. In vitro and in vivo activity of moxifloxacin against community respiratory tract pathogens. Clin Drug Invest 1999;18: 57-78.
9. Dinis PB, Monteiro MC, Martins ML, et al. Sinus tissue pharmacokinetics after oral administration of amoxicillin/clavulanic acid. Laryngoscope 2000; 110:1050-1055.
10. Gehanno P, Darantiere S, Dubreuil C, et al. A prospective, multicentre study of moxifloxacin concentrations in the sinus mucosa tissue of patients undergoing elective surgery of the sinus. J Antimicrob Chemother 2002;49:821-826.
11. Guay DRP. Short-course antimicrobial therapy of respiratory tract infections. Drugs 2003;63:2169-2184.
12. Pichichero ME, Cohen R. Shortened course of antibiotic therapy for acute otitis medica, sinusitis and tonsillopharyngitis. Pediatr Infect Dis J 1997;16: 680-695.
13. Williams JW Jr, Holleman DR Jr, Samsa GP, et al. Randomized controlled trial of 3 vs 20 days of trimethoprim/sulfamethoxazole for acute maxillary sinusitis. JAMA 1995;273:1015-1021.
14. Casiano RR. Azithromycin and amoxicillin in the treatment of acute maxillary sinusitis. Am J Med 1991;91(Suppl 3A):27S-30S.
15. Khong TK. Shortened therapies in acute sinusitis. Hosp Pract 1996;31 (Suppl 1):11-13.
16. Klapan I, Culig J, Oreskovic K, et al. Azithromycin versus amoxicillin/clavulanate in the treatment of acute sinusitis. Am J Otolaryngol 1999;20:7-11.
17. Gehanno P, Beauvillain C, Bobin S, et al. Short therapy with amoxicillinclavulanate and corticosteroids in acute sinusitis. Scand J Infect Dis 2000;32: 679-684.
18. Roos K, Brunswig-Pitschner C, Kostrica R, et al. Efficacy and tolerability of once-daily therapy with telithromycin for 5 or 10 days for the treatment of acute maxillary sinusitis. Chemotherapy 2002;48:100-108.
19. Sher LD, McAdoo MA, B ettis RD, et al. A multicenter, randomized, investigator-blinded study of 5- and 10-day gatifloxacin versus 10-day amoxicillin/clavulanate in patients with acute bacterial sinusitis. Clin Ther 2002;24: 269-281.
20. Ferguson BJ, Anon J, Poole MD, et al. Short treatment durations for acute bacterial rhinosinusitis: Five days of gemifloxacin versus 7 days of gemifloxacin. Otolaryngol Head Neck Surg 2002;127:1-6.
21. Ng DK, Chow PY, Leung L, et al. A randomized controlled trial of azithromycin and amoxicillin/clavulanate in the management of subacute childhood rhinosinusitis. J Paediatr Child Health 2000;36:378-381.
22. Hoberman A, Paradise JL, Burch DJ, et al. Equivalent efficacy and reduced occurrence of diarrhea from a new formulation of amoxicillin/clavulanate potassium (Augmentin) for the treatment of otitis media in children. Pediatr Infect Dis J 1997;16:463-470.
23. Henry DC, Riffer E, Sokol WN, et al. Randomized double-blind study comparing 3- and 6-day regimens of azithromycin with a 10-day amoxicillin-clavulanate regimen for treatment of acute bacterial sinusitis. Antimicrob Agents Chemother 2003;47:2770-2774.
24. Chen DK, McGeer A, de Azavedo JC, et al, and The Canadian Bacterial Surveillance Network. Decreased susceptibility of Streptococcus pneumoniae to fluoroquinolones in Canada. N Engl J Med 1999;341:233-239.
25. Linares J, de la Campa AG, Pallares R. Fluoroquinolone resistance in Streptococcus pneumoniae [letter]. N Engl J Med 1999;341:1546-1547.
26. Ho PL, Que TL, Tsang DN, et al. Emergence of fluoroquinolone resistance among multiply resistant strains of Streptococcus pneumoniae in Hong Kong. Antimicrob Agents Chemother 1999;43:1310-1313.
27. Ho PL, Yung RW, Tsang DN, et al. Increasing resistance of Streptococcus pneumoniae to fluoroquinolones: Results of a Hong Kong multicenter study in 2000. J Antimicrob Chemother 2001;48:659-665.
28. Confalonieri M, Potena A, Carbone G, et al. Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med 1999; 160:1585-1591.
29. Dean NC, Suchyta MR, Bateman KA, et al. Implementation of admission decision support for community-acquired pneumonia. A pilot study. Chest 2000;117:1368-1377.
30. Ferraro MJ, et al. Massachusetts General Hospital, Boston, MA, 2 CMI, Wilsonville, OR, 3 Micron Research, Ely, United Kingdom. Abstract 650 Prevalence of Fluoroquinolone Resistance amongst Streptococcus pneumoniae Isolated in the United States during the Winter of 2000-01. Paper presented at: 42nd ICAAC Abstracts, American Society for Microbiology; Sept. 27-30, 2002; San Diego, Calif.
31. Mandell LA, Bartlett JG, Dowell SF, et al. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis 2003;37:1405-1433.
32. Heffelfinger JD, Dowell SF, Jorgensen JH, et al. A report from the drug-resistant Streptococcus pneumoniae Therapeutic Working Group. Management of community-acquired pneumonia in the era of pneumococcal resistance. Arch Intern Med 2000;160:1399-1408.
33. Centers for Disease Control and Prevention web site. Drug-resistant Streptococcus pneumoniae disease. www.cdc.gov/ncidod/dbmd/diseaseinfo/drugresisstreppneum_t.htm. Accessed Feb. 11, 2004.
34. Berg O, Carenfelt C. Analysis of symptoms and clinical signs in the maxillary sinus empyema. Acta Otolaryngol 1988;105:343-349.
35. Williams JW Jr., Simel DL, Roberts L, et al. Clinical evaluation for sinusitis. Making the diagnosis by history and physical examination. Ann Intern Med 1992;117:705-710.
36. Lindbaek M, Hjortdahl P, Johnsen UL. Use of symptoms, signs, and blood tests to diagnose acute sinus infections in primary care: Comparison with computed tomography. Fam Med 1996;28:183-188.
37. Lindbaek M, Johnsen UL, Kaastad E, et al. CT findings in general practice patients with suspected acute sinusitis. Acta Radiol 1996;37:708-713.
38. Cotter CS, Stringer S, Rust KR, et al. The role of computed tomography scans in evaluating sinus disease in pediatric patients. Int J Pediatr Otorhinolaryngol 1999;50:63-68.
39. Gordts F, Clement PA, Destryker A. et al. Prevalence of sinusitis signs on MRI in a non-ENT paediatric population. Rhinology 1997;35:154-157.
40. Chong VF, Fan YF. Comparison of CT and MRI features in sinusitis. Eur J Radiol 1998;29:47-54.
41. Adam D, Scholz H, Helmerking M. Short-course antibiotic treatment of 4782 culture-proven cases of group A streptococcal tonsillopharyngitis and incidence of poststreptococcal sequelae. J Infect Dis 2000;182:509-516.
42. Portier H, Chavanet P, Gouyon JB, et al. Five day treatment of pharyngotonsillitis with cefpodoxime proxetil. J Antimicrob Chemother 1990;26(Suppl E): 79-85.
43. Portier H, Chavanet P, Waldner-Combernoux A, et al. Five versus ten days treatment of streptococcal pharyngotonsillitis: A randomized controlled trail comparing cefpodoxime proxetil and phenoxymethyl penicillin. Scand J Infect Dis 1994;26:59-66.
44. Cooper RJ, Hoffman JR, Bartlett J, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Ann Emerg Med 2001;37: 711-719.
45. Hayes CS, Williamson H Jr. Management of group A beta-hemolytic streptococcal pharyngitis. Am Fam Physician 2001;63:1557-1564.
46. American Academy of Pediatrics. Subcommittee on Management of Sinusitis and Committee on Quality Improvement. Clinical Practice Guideline: Management of sinusitis. Pediatrics 2001;108:798-808.
47. Snow V, Mottur-Pilson C, Hickner JM, et al. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Intern Med 2001;134:495-497.
48. Acute Sinusitis in Adults. Bloomington, Minn: Institute for Clinical Systems Improvement (ICSI), 2002. Available at: www.icsi.org. Accessed on June 17, 2003.
49. Denny FW, Wannamaker LW, Brink WR, et al. Prevention of rheumatic fever: Treatment of the preceding streptococcic infection. JAMA 1950;142:151-153.
50. Gehanno P, Taillebe M, Denis P, et al. Short-course cefotaxime compared with five-day co-amoxyclav in acute otitis media in children. J Antimicrob Chemother 1990;26(Suppl A):29-36.
51. Cohen R, Navel M, Grunberg J, et al. One dose ceftriaxone vs ten days of amoxicillin/clavulanate therapy for acute otitis media. Pediatr Infect Dis J 1999;18:403-409.
52. Rakkar S, Roberts K, Towe BF, et al. Moxifloxacin versus amoxicillin clavulanate in the treatment of acute maxillary sinusitis: A primary care experience. Int J Clin Pract 2001;55:309-315.
53. Burke T, Villanueva C, Mariano H Jr, et al. Comparison of moxifloxacin and cefuroxime axetil in the treatment of acute maxillary sinusitis. Sinusitis Infection Study Group. Clin Ther. 1999;21:1664-1677.
54. Siegert R, Gehanno P, Nikolaidis P, et al. A comparison of the safety and efficacy of moxifloxacin (BAY 12-8039) and cefuroxime axetil in the treatment of acute bacterial sinusitis in adults. Sinusitis Study Group. Respir Med. 2000;94:337-344.