CLINICAL PRACTICE GUIDELINE

This Clinical Practice Guideline (CPG) and accompanying patient education were developed by a multidisciplinary team, under the leadership of Nebraska Health Network s Primary Care Clinical Integration Workgroup. SEPTEMBER 2016 Based on national guidelines and emerging evidence and shaped by expert local opinion, this CPG provides practical strategies for early recognition, diagnosis and effective treatment of acute rhinosinusitis. CLINICAL PRACTICE GUIDELINE Acute Rhinosinusitis Treatment for Adults GOALS The goal of the Acute Sinusitis Clinical Practice Guideline (CPG) is to prescribe antibiotics only when appropriate and to help decrease the overall prescribing of inappropriate antibiotics. The information in this CPG assists primary care teams to determine the difference between viral and bacterial acute sinus infections, provides evidencebased treatment options for both diagnoses, and offers important tools and resources for patient education. Overview The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020. Antibiotic resistance is a growing problem and the main cause of this problem is the inappropriate use of antibiotics in the outpatient setting. 1 Antiobiotics are also associated with the risk for adverse drug reactions. These adverse reactions account for 20% of visits to the emergency department for adverse drug events. 2 The CDC estimates that at least 1 in 3 prescriptions in the outpatient setting are not essential to patient health. Approximately 44% of outpatient antibiotic prescriptions are used to treat acute respiratory conditions, likely viral. Reducing inappropriate use is essential to reduce both antibiotic resistance and adverse events. 3 GOAL: 50% LESS ANTIBIOTICS BY 2020 1/3 PRESCRIPTIONS T ESSENTIAL INSIDE 1 OVERVIEW/GOALS 2 TREATMENT 3 CLINICAL ALGORITHM 5 TEAM MEMBERS 5 PATIENT EDUCATION 6 RESOURCES & REFERENCES Acknowledgements/Development Team: Ivan Abdouch, MD Trevor Van Schooneveld, MD, FACP Mark Omar, MD Andrew Vasey, MD Tom McElderry, MD Dale Agner, MD Elaine McCord, MSN, RN Jana Uryasz, MSN, RN Nebraska Health Network (NHN) Clinical Practice Guidelines are developed to assist clinicians by providing an analytical framework for the evaluation and treatment of selected common problems encountered in patients. They are not intended to establish a protocol for all patients with a particular condition. Clinicians must exercise independent judgment and make decisions based upon the situation presented. While great care has been taken to assure the accuracy of the information presented, the reader is advised that NHN cannot be responsible for continued currency of the information, for any errors or omissions in this guideline, or for any consequences arising from its use. This Clinical Practice Guideline should not be used or reprinted without written consent from the Nebraska Health Network. Approved Date: 8/09/2016 Review Date: 08/09/2018

TREATMENT Antibiotic Therapy for BACTERIAL Rhinosinusitis 4 Treatment should start as soon as possible after diagnosis of Acute Bacterial Sinusitis. Amoxicillin with or without clavulanate is the recommended medication for initial empiric antibiotic therapy for a 5-7 day treatment course. Routine coverage for MRSA during initial antibiotic therapy is T recommended. Patients who present with any of the symptoms of acute bacterial sinusitis and those who have a risk for antibiotic resistance should be prescribed highdose amoxicillin-clavulanate. Azithromycin use is discouraged because of resistance. Doxycycline should be used as the first line agent for adults with either a penicillin or beta-lactam allergy. A respiratory fluoroquinolone (levofloxacin or moxifloxacin) may be used if doxycycline is contraindicated. Intranasal corticosteroids can be used as adjunctive therapy to antibiotics, primarily in those with a history of allergic rhinitis. When to Refer to a Specialist 5 Severe infection (high persistent fever with temperature > 102 F; orbital edema; severe headache, visual disturbance, altered mental status, meningeal signs) Recalcitrant infection with failure to respond to extended courses of antibiotic therapy Immunocompromised Multiple comorbid conditions which could compromise response to treatment Unusual or resistant pathogens Fungal sinusitis or granulomatous disease Nosocomial infection Anatomic defects causing obstruction and requiring surgical intervention Recurrent episodes (3-4 per year) suggesting chronic sinusitis Chronic sinusitis with recurrent acute exacerbations Evaluation of immunotherapy for allergic rhinitis Symptomatic Therapy for Acute VIRAL Upper Respiratory Infection 6,7 Patient should receive education on the difference between viral and bacterial infections and why antibiotics are not helpful or healthy. Patient should rest and drink plenty of fluids. Over the counter (OTC) medications may help with symptom relief but will not decrease the duration of the illness. ICD-10 Information for Acute vs. Chronic Sinusitis Chronic Sinusitis, unspecified J32.9 Acute Sinusitis, unspecified J01.90 Symptomatic therapy recommendations: - Rest and fluids - Acetaminophen/ibuprofen for discomfort and fever - Saline nasal rinses and/or decongestants - Cough suppressants - Intranasal corticosteroids - Avoid smoking Acute Upper Resp infection, unspecified JO6.9 Documentation required for all ICD-10 diagnoses Sinus location involved Chronicity (acute, subacute, chronic or unspecified) Recurrence (recurrent or not specified)

ACUTE RHISINUSITIS TREATMENT in Adults 5 Patient presents with URI symptoms RECOMMEND SYMPTOMATIC THERAPY: Rest and fluids Saline nasal rinse and/or decongestants Acetaminophen/ibuprofen Cough suppressants for discomfort and fever Intranasal steroids Identify presence of: Persistent symptoms and not improving (>10 days) Severe symptoms or high fever ( 102 F) Purulent nasal discharge or facial pain Worsening symptoms after initial improvement LIKELY VIRAL LIKELY BACTERIAL Has risk factors for resistance: Recent antibiotic treatment (within 30 days) Hospitalization in the past 5 days Pre-existing conditions Immunocompromised Educate patient to notify office if no improvement in 5-7 days after office visit Has Penicillin Allergy Has Penicillin Allergy Identify symptom improvement Follow up Visit OR Prescription for antibiotics No further treatment Recommend Antibiotic Therapy: Amoxicillin: 500 mg PO TID or 1000mg PO BID --OR-- Amoxicillin with Clavulanate 500/125 mg PO TID or 875/125 mg PO BID Recommend Antibiotic Therapy: Doxycycline 100 MG PO BID OR 200 MG PO Daily Recommend Antibiotic Therapy: Amoxicillin/ clavulanate 2000mg/125mg PO BID (1000mg/62.5mg, 2 tabs, BID) Recommend Antibiotic Therapy: Levofloxacin 500mg daily OR Moxifloxacin 400mg daily Core Treatment Principles: - Recommend antibiotic therapy for 7 days dependent on physician discretion, when needed. - Address sleep/pain and other symptom management therapies - Provide a definitive date of if no better by call the office. - Identify other unrecognized or undertreated conditions may need consideration - Use of Azithromycin is discouraged because of resistance.

TEAM MEMBERS The Triple Aim of the Nebraska Health Network (NHN) is to improve the quality and safety of our patient care and improve the patient experience while enhancing affordability. The goal of the NHN is to standardize treatment across our health systems and providers. Clinical Practice Guidelines (CPGs) and resources are developed by NHN workgroups to implement evidence-based care and best practice standards within our network. Team Roles: There is an on-going commitment from the NHN to develop and implement current evidence-based CPGs. Educating yourself and your patients on these best practice guidelines helps your office achieve the Triple Aim. Team Resources: Patient-centered teams work more efficiently and effectively to provide high quality care that s known to improve health outcomes and patient satisfaction. 8 PATIENT EDUCATION Patient Education is essential for improving health behaviors and overall health outcomes. GOALS 1 Simplify communication and confirm understanding (teach-back). 2 Support patients efforts to improve their health (shared decision making). 3 SUGGESTED TEACHING RESOURCES: StayWell Healthsheets: Acute Sinusitis Causes of Sinusitis Preventing Sinusitis ExitCare Education Leaflets: Sinusitis, Adult Sinusitis, Adult Easy to Read Additional Resources: Centers for Disease Control and Prevention http://www.cdc.gov/bloodpressure/docs/ ConsumerEd_HBP.pdf Health Literacy Universal Precautions: 9 Assume all patients have difficulty comprehending health information and accessing health services. This section provides key talking points to support health literacy. Definitions: Acute sinusitis is an inflammation (irritation and swelling) of the sinuses. Risk Factors: Acute sinusitis often develops after a cold or flu-like illness. Colds and flu are caused by germs called viruses which may spread to the sinuses. In a small number of cases, germs called bacteria occur after an infection that started as a virus. This can cause a bacterial sinus infection which can make the infection worse and last longer. Other factors may cause the sinuses to become infected, including: Nasal allergies Asthma Cigarette smoking Facial injury or surgery to nose or cheeks Other causes of a blockage to the sinus drainage channels, such as growths (nasal polyps) Symptoms: Symptoms may vary by patient, but can include: Nasal congestion Facial pain Cough Fullness in the ears Fever Thick green or Headache yellow nasal Tiredness drainage Diagnosis: Sinus infections can be difficult to diagnose in the early stages because it can feel like a common cold. Doctors will diagnose acute sinusitis based on symptoms, medical history and an office examination. - The doctor asks about symptoms and how long they last. A common cold usually improves in five to seven days, while an untreated sinus infection can last three weeks or longer. - The doctor may examine ears, nose and throat and press on face to identify tenderness over sinuses. Prevention and Lifestyle Modifications: Patients can help decrease their risk of developing sinusitis. Quit smoking. Smoke irritates nasal passageways and increases the chance of infections. Avoid allergens. Nasal allergies can trigger sinus infections. By identifying the allergen (the substance causing the allergic reaction) and avoiding it, the patient helps prevent sinusitis. Wash your hands frequently. Many bacterial infections start with a virus spread by contact with germs. The following may help reduce the risk of sinusitis when patients have congestion: Drink lots of water. This thins nasal secretions and keeps mucous membranes moist. Use steam to soothe nasal passages. Breathe deeply while standing in a hot shower, or inhale the vapor from a basin filled with hot water while holding a towel over your head. Avoid blowing your nose with great force. This pushes bacteria into the sinuses. 2016 Zynx Health Incorporated

REFERENCES & RESOURCES 1. Fleming-Dutra K, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873. doi:10.1001/jama.2016.4151. 2. Harris A, Hicks L, Qaseem A,et al. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-vlaue care from the american college of physicians and the centers for disease control and prevention. Annals of Internal Medicine. 2016; 164(6): 425-435. 3. CDC: 1 in 3 antibiotic prescriptions unnecessary. Centers for Disease Control and Prevention Website. http://www.cdc.gov/media/releases/2016/p0503-unnecessary-prescriptions.html. Accessed September 2016. 4. Infectious Diseases Society of America. Rhinosinusitis Guidelines Pocketcard. Available online at: http://eguideline.guidelinecentral.com/i/71828-rhinosinusitis. Accessed June 2016. 5. Chow, AW, Benninger, MS, Brook, I et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. CID. 2012. DOI: 10.1093/cid/cir1043. 6. Get Smart: Know When Antibiotics Work Symptom Relief. Centers for Disease Control and Prevention Website. http://www.cdc.gov/getsmart/community/for-patients/symptom-relief.html. Updated April, 2015. Accessed June, 2016. 7. Zalmonovici Trestioreanu A, Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database of Systematic Reviews. 2013. Issue 12. Art No: CD005149. DOI: 10.1002/14651858.CD005149.pub.4. 8. Team-Based Care. National Institute of Diabetes and Digestive and Kidney Diseases Website. http://www.niddk.nih.gov/health-information/health-communication-programs/ndep/health-care-professionals/ practice-transformation/team-based-care/pages/default.aspx. Accessed May 2016 9. Health literacy universal precautions toolkit. Agency for Healthcare Research and Quality Website. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html. Reviewed May, 2016. Accessed April, 2016.