Prefe f rred d t e t rm: : rhi h no n s o inu n s u iti t s

Transcription

1 HELP It s my sinuses! An overview of pharmacologic treatment of sinusitis Objectives Identify types of sinusitis and underlying pathology Examine common evidence based pharmacologic treatment for sinusitis Discuss the issues which impede successful pharmacologic management Participate in an interactive discussion on pharmacologic treatment of sinusitis GOAL To improve knowledge and clinical reasoning skills to assist you in becoming an expert prescriber Review Anatomy - Sinuses Frontal, Maxillary, Ethmoid, Spenoid Physiology Air filled Drainage issues Types of Sinusitis Incidence 37 million adults in USA 1 in 7 adults have one episode/year Increased ages Costs Direct - estimated $3 Billion/ year Meds clinic/er visits tests Indirect Lost work / decreased quality of life Based on symptom duration Acute < 4 weeks (ARS) Sub-acute 4-12 weeks Chronic Recurrent > 12 weeks (CRS) 4 or more / year Preferred term: rhinosinusitis concurrent inflammation of nasal mucosa 1

2 Viral Bacterial Fungal Microbiology Pathogen Distribution S. pneumonia 40% H. influenza 35% M. catarrhalis 4% Staph aureus 3% Anaerobes 7% Streptococcus species 4% Viral Type - associated with URI (common cold) - most common etiology - resolves within 7-10 days % cases complicated by bacterial infection Bacterial Type - May also be self-limited limited disease - - studies suggest 40-69% ABRS may clear infections spontaneously* * BUT dx based on clinical symptoms - may have included viral infections * Falagas ME,Giannopoulou KP, Vardakas KZ, et al. Comparison of antibiotics with placebo for treatment of acute sinusitis: a meta-analysis analysis of randomized controlled trials. Lancet Infect Dis 2008;8:543 Complications Local form mucocele/pyocele Abscess - can lead to fistula Orbital Cellulitis / inflammation of optic nerve Intracranial extension Meningitis / epidural & subdural abscess Cavernous sinus thrombosis Brain abscess 40% mortality rate Dilemma To treat or not to treat? That is the question. 2

3 Viral vs. Bacterial ABRS? Can t tell difference in first 10 days Suspect ABRS 1. Persistent symptoms 10 or more days with NO clinical improvement 2. Onset with severe symptoms that last at least 3 consecutive days at onset fever >39 degrees C or 102 degrees F purulent nasal discharge or facial pain Viral vs. Bacterial ABRS? ABRS (con t) 3. Onset with worsening symptoms following URI that lasted 5-6 days -initially improving Management Antibiotic Tx * eliminate infection * prevent complications Viral (AVRS) Expected to resolve within 10 days Supportive care : Symptom Relief Analgesia acetaminophen/ NSAIDs Pain relief Saline Irrigation Reduce need for pain med/ comfort Topical glucocorticoids Decrease mucosal inflammation Allow improved sinus drainage Symptom relief (con t) Topical decongestants Subjective sense of improved nasal patency May provoke inflammation use sparingly Oral decongestants Questionable efficacy Antihistamines Not recommended over drying of mucosa Mucolytics Thin secretions/ may improve drainage GUIDELINES Clinical practice guideline: Adult Sinusitis Otolaryngology Head and Neck Surgery (2007) 137,S1-S31S31 GUIDELINES ISDA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults Infectious Diseases Society of America Clinical Infectious Diseases Advance Access Published March 20,2012 Algorithm 3

4 Efficacy of systemic treatment Difficult to assess from the literature -- etiology of symptoms not clear - few pre- treatment cultures 2008 meta-analysisanalysis cure/ improvement rate 77% with antibiotics 68% with placebo Decision to treat Clinical evaluation Include factors: age, general state of health & comorbidities Meet clinical criteria ABRS Rationale Shorten duration of illness Relieve symptoms Prevent recurrent infection or complications Antibiotics Prior first-line: amoxicillin narrow spectrum / low cost resistance respiratory pathogens Pneumococcal and H. influenzae Current first-line: amoxicillin-clavulanate clavulanate Improves coverage for resistant H. influenzae and M. catarrhalis Recommended empiric therapy for non- penicillin allergic adults Amoxicillin-clavulate clavulate dose: 500mg/125mg po TID or 875mg/125mg po BID Recommend high dose (2 grams po BID) Geographic regions penicillin-nonsusceptible nonsusceptible S. pneumonia >10% - 65 years and older - recently hospitalized - treated with antibiotic prior month - immunocompromised Penicillin allergy considerations doxycycline respiratory fluoroquinolone levofloxacin Moxifloxacin A respiratory fluroquinolone is effective BUT concern with overuse Attempt to slow development of resistance to this class Macrolides NOT recommended clarithromycin erythromycin azithromycin clarithromycin dirithromycin roxithromycin high rates of resistance to S. Pneumoniae 4

5 Antibioticc Treatment Second or 3rd generation cephalosporins NOT recommended cefactor cefamadole cefoxitin cefmetazole cefonicid cefuroxime etc. high rates of resistance to S. Pneumoniae Antibiotic treatment Sulfonamides NOT recommended sulfamethizole sulfamethoxazole sulfisoxazole trimethoprim-sulfamethoxazole high rates of resistance to H. influenzae Initial treatment duration Traditionally days IDSA guidelines 5-7 day course Side effects Considerations Bacterial eradication within 72 hours with appropriate antimicrobial treatment Systemic Glucocorticoids Improved symptom control day 3-7 Not first line treatment Side effect profile consideration Discussion for appropriate use Analgesics Acetaminophen Liver issues NSAIDs GI considerations Symptom Relief Patient expectations 5

6 Patient Expectations That s all you re giving me??? Education Etiology Natural course Adjunctive measures. Positive interaction/ partnership Symptomatic Therapy Humidification/ vaporizer Warm compressed Hydration Hydration Smoking cessation Balanced Nutrition Saline Irrigation Options/ considerations Saline Irrigation Mechanical irrigation May decrease need for pain meds Improve comfort -especially with frequent or chronic issues Limited evidence Products available Topical steroids Inhaled nasal steroids Theory: Decrease mucosal inflammation Improve sinus drainage Not good research some benefit shown Most benefit in population with underlying allergic rhinnitis Inhaled Nasal Steroids Options Momestasone Flunisolide Fluticasone Cromelyn Ipratropium Topical Decongestants Some role with viral rhinosinusitis subjective improved nasal breathing NOT helpful with ABRS/ antibiotic tx Oxymetazoline Avoid rebound limit to 3 days May cause mucosal inflammation 6

7 Oral Decongestants Reduce edema Facilitate drainage Role with Eustachian tube dysfunction More common with AVRS Recommend short course (3-5 days) Pseudoephedrine Caution with HTN, CV disease, BPH Alpha adrenergic effects Antihistamines NOT recommended Over-drying mucosa Causes more discomfort No studies on efficacy Side effect dry mouth drowsiness Mucolytics Thin secretions May improve drainage Assist with mucous clearance No published studies to support use Participant experience? anecdotal Observation Watchful waiting Supportive tx for 7 days from diagnosis If mild symptoms Assurance of follow-up If no improvement OR gets worse Start antimicrobial treatment Change in practice? issues Treatment Failure Reasons for tx failure Resistant pathogens Inadequate dosing Structural abnormalities Noninfectious etiology ISDA Guidelines for second line treatment Amoxicillin-clavulanate clavulanate 2000mg/ 125mg po BID levofloxacin 500mg po daily moxifoxacin 400mg po daily Considerations Biofilm Produced by staph aureaus/ pseudomonas Fungal infections Structural Abnormalities Polyps 7

8 Considerations Further work-up - culture CT Surgery Dental issues Complications ICU/intubations (1-8% Gram neg organism Fungal immunosuppressed/ DM Chronic Rhinosinusitis Inflammation Contributing Factors Allergens Irritants Immunodeficiency Recommendations Ciliary / mucosal abnormality Nebulized Antimicrobials Small particles over a large area Compliance Issues Providers experiences Off label use Basis Options Suggestions Discussion Medical-Legal Issues Questions?? Documentation Complications Follow-up Establish rapport 8