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New Sinusitis Guideline Eases Antibiotic Use

The new clinical practice guideline for adult sinusitis that was published in April will be discussed in a Mini-seminar today. The new guideline makes a stronger recommendation on withholding antibiotics, addresses adjunctive therapies, and includes patient materials.

“AAO-HNSF Clinical Practice Guideline: Adult Sinusitis Update” will be presented from 7:30 am-9:00 am today in Ballroom C1 of the convention center. Other information of interest in the guideline addresses symptomatic relief and therapies to avoid for chronic sinusitis, and an algorithm for diagnosis and treatment.

“Even those who have read the guideline may have questions because some of the information is a little different than common practice. It is helpful to hear at a Miniseminar the rationale as to why these decisions were made and the basis of the recommendations,” said Richard M. Rosenfeld, MD, MPH, chair of the committee that wrote the guideline.

Guideline highlights that will be addressed include acute sinusitis, the use of antibiotics, symptomatic relief, and chronic sinusitis.

Acute Sinusitis

In the previous guideline, acute sinusitis was diagnosed as persistent symptoms beyond 10 days, including nasal discharge, congestion, and pressure in the face. The new guideline adds that antibiotics should only be used if symptoms do not improve after 10 days.

“We acknowledge in this guideline that the viral infection can last beyond 10 days as long as patients are improving,” Dr. Rosenfeld said. “When it goes 10 days or longer without improving, then it is more likely to be bacterial. That is a key point—that we were probably overdiagnosing a bit under the old guideline, and this corrects that problem.”

Antibiotics

The recommendation for the use of antibiotics has been changed to allow more watchful waiting before starting a course of antibiotics, Dr. Rosenfeld said.

“We have made this the recommendation, which is a stronger level of statement and evidence,” he said. We recommend that even after you diagnose a bacterial sinus infection, it is perfectly fine to withhold the antibiotic. It is acceptable to allow the patient up to seven days to get better on their own. If you do that, about 85 percent will get better on their own.

“Previously, we said that if you are very sick, with more severe symptoms, you need to take an antibiotic, but more recent evidence does not support that as necessary.”

Symptomatic Relief

Adjunctive therapies also are included in the new guideline, and they are part of the patient-friendly information that is written in lay terms.

“We recommend using daily saline rinses and nasal steroid sprays to relieve symptoms of acute sinus infections as well as chronic sinus infections. Washing your nose with salt water is a very good way to get relief,” Dr. Rosenfeld said.

Chronic Sinusitis

Management of chronic sinusitis is emphasized as part of the guideline, and in particular, it addresses the important role of polyps in the nose because it affects treatment.

“It is important to look for polyps early, once you have diagnosed chronic sinusitis,” Dr. Rosenfeld said. “The patients with polyps are more likely to need surgery and intervention, and are less likely to respond to certain medications than patients who do not have polyps.

“We have gone to great lengths to say that patients should not get any type of antifungal therapy for chronic sinus infection because it does not work, and it potentially has a lot of side effects, particularly oral fungal therapy.”