• Summary
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• Background
• Clinical Diagnosis
• Investigation
• Treatment
• Non-Antimicrobial Treatment
• Empirical Antimicrobial Treatment
• Directed Antimicrobial Treatment (when microbiology results are known)
• Switch to oral agent(s)
• Treatment Failure

History
Diagnose acute bacterial rhinosinusitis in patients with a sudden onset of either 2 major criteria or 1 major and ≥1 minor criteria:

Major criteria:

1. nasal blockage / obstruction / congestion
2. nasal discharge (anterior / posterior nasal drip):

Minor criteria:

1. facial pain / pressure
2. reduction or loss of smell

AND with worsening symptoms after 5 days (having initial improved) OR persistent symptoms 10 days after onset.

Assess if:

1. acute rhinosinusitis (symptoms present <12 weeks and no previous antimicrobial treatment); or
2. persisting rhinosinusitis (symptoms present > 12 weeks or previous antimicrobial treatment); or
3. complicated rhinosinusitis - Refer to ENT (with signs of recognized complications: orbital cellulitis, cavernous sinus thrombosis, subdural empyema, brain abscess, or severe sepsis).

Examination

• Measure temperature and physiological observations (pulse, blood pressure, respiratory rate).
• Perform anterior rhinoscopy (with an auroscope) to confirm purulent nasal discharge.
• Assess facial swelling / erythema over the maxilla or frontal sinus.
• All but the sphenoidal sinuses can be palpated for tenderness

Investigations

• Full blood count and urea/electrolytes (inpatients);
• Blood cultures x2 (complicated sinusitis only, before antimicrobial therapy);
• Para nasal sinus and brain CT with contrast - (complicated sinusitis only);
• Endoscopic middle meatal swab (ENT)- (persisting/complicated sinusitis only)
• x-rays – not routinely recommended;

Non-Antimicrobial Management
Recommended for patients with mild moderate acute viral or bacterial sinusitis
Analgesia (recommended)
Intranasal steroid (mometasone furoate) 200micrograms 12-hourly for 10 days (recommended)
Intranasal decongestant (ephedrine 0.5%)  two drops 8-hourly for 5 days (optional)
Nasal douching 12-hourly (optional)

Antimicrobial treatment
Recommended ONLY for patients with moderate severe acute bacterial sinusitis SEE ALGORITHM

*Linezolid has a number of drug interactions/contraindications. Please see full guidance to check suitability for the patient. This is an off-label use of Linezolid and Teicoplanin ; the patient should be informed of this.

Duration of treatment 10 days
Specialist referral – refer all cases of persisting and complicated sinusitis to ENT prior to commencing antimicrobial therapy unless severe sepsis/septic shock present.

Treatment failure
See full guideline

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Rhinitis and sinusitis usually coexist and are concurrent in most individuals thus the correct terminology is now rhinosinusitis. Rhinosinusitis is defined as an inflammatory condition affecting the nose and paranasal sinuses.  It can be caused by infection or allergy. It is a prevalent and important cause of ill health accounting for 15% to 21% of all adult outpatient prescriptions for antibiotics^{1, 2}. Only infective causes are considered in this guideline.

The paranasal sinuses are lined with ciliated pseudostratified epithelium, which is not normally colonized by bacteria despite being directly connected to the nasal cavity.  The paranasal sinuses are cleared by mucociliary transport through small openings in the lateral nasal wall; the oseomeatal complex. The mechanism for maintaining this sterile environment is unknown but is likely to involve a combination of a patent osteomeatal complex, mucociliary clearance, mucosal and systemic immunity³.

Rhinosinusitis can be classified according to the site of acquisition (hospital or community), the immune status of the host, the aetiology (bacterial, viral, fungal) and the duration of illness².

More practical, in terms of subsequent management is the distinction between:

1. acute rhinosinusitis, in which symptoms have been present for less than 12 weeks and settle spontaneously or with a single course of antimicrobial therapy or after surgical intervention.

2. Persisting rhinosinusitis, in which symptoms have been present for over 12 weeks or have failed a previous course of antimicrobial therapy

3. Complicated rhinosinusitis in which sinusitis is present together with any of its recognized complications (orbital cellulitis, cavernous sinus thrombosis, subdural empyema, brain abscess, severe sepsis/septic shock).

The distinction between hospital acquired (usually defined as that developing >72 hours after admission) and community-acquired infection is relevant to the likely causative organism. Classification according to patient risk group such as the immunocompetence of the host is also relevant to the likely infecting pathogens and approach to therapy.

Acute community-acquired rhinosinusitis can affect adults of any age but young adults between the ages of 20 and 40 are most commonly affected.  Sinus disease is an inherent part of the common cold syndrome, i.e. a high proportion of patients with a “common cold” have viral rhinosinusitis. In this situation cilia can fail to move sinus material to the ostium, local swelling causes occlusion and clearance of sinus material is impaired, resulting in symptoms which usually settle in less than 10 days. Bacterial infection of the sinus may follow an acute viral infection typically with increasing symptoms after 5 days or persistent symptoms beyond day 10. Bacterial sinusitis may also occur as a result of direct spread from a periodontal source of infection.²

Respiratory viruses (e.g. coronavirus, rhinovirus) are the most common cause of rhinosinusitis.

The most common bacterial causes of rhinosinusitis in adults are Streptococcus pneumoniae and Haemophilus influenzae with other Streptococcus species (beta and alpha haemolytic including Streptococcus anginosus group sometimes called “milleri”), Moraxella catarrhalis, anaerobes and Staphylococcus aureus accounting for most other cases.  Fungi rarely cause acute community acquired sinusitis. ^{1, 4}

There is a great potential for inappropriate antimicrobial prescribing for many acute upper respiratory tract infections because of the prevalence of self-limiting viral infections. It is estimated that only 0.5% to 2% of viral rhinosinusitis is complicated by bacterial infection which is usually mild and also self limiting. Acute bacterial rhinosinusitis probably affects 1 in 10 people at some point in their lives. A UK general practice can expect to see about 250 cases of acute bacterial rhinosinusitis every 10,000 person-years. The problem of choosing an appropriate antimicrobial agent, when one is indicated, is exacerbated by the increasing prevalence of antimicrobial resistance among common pathogens.^{5, 6}

Patients with rhinosinusitis and brain abscesses should be managed according to LTHT guidelines for the management of brain abscesses in addition to ENT surgery input.

Patients with orbital complications of rhinosinusitis LTHT guidelines for the management of orbital cellulitis in addition to ENT surgery input.

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An important diagnostic problem is distinguishing between viral and bacterial rhinosinusitis (i.e microbiological diagnosis) and thus identifying patients for whom antimicrobial therapy is likely to be beneficial.  Because viral rhinosinusitis is a self-limiting condition, the chronology of infection is important.

Acute rhinosinusitis is defined as²:
a sudden onset of either 2 major or 1 major and ≥ 1 minor criteria:

Major criteria:
i. nasal blockage / obstruction / congestion
ii. nasal discharge (anterior / posterior nasal drip):

Minor criteria:
i. facial pain / pressure
ii. reduction or loss of smell

Acute bacterial rhinosinusitis is suspected with worsening symptoms after 5-days (having initial improved) OR persistent symptoms 10 days after onset.

History
Patients with the common cold syndrome frequently have sinus involvement and some of the symptoms of the common cold such as headache, post nasal drip, nasal mucopus and obstruction may be attributable to sinusitis. Patients with acute sinusitis classically present with pain over the affected sinus, facial pain, fevers and blocked nose but any combination of symptoms associated with the common cold syndrome may also be present. Involvement of the sphenoid sinus classically causes pain radiating to the top of the head.

Some clinical findings have a stronger association with acute bacterial infection such as purulent secretions (persisting or recurring), dental pain, and pain bending forward, but the specificity of these is generally poor - ranging between 76 and 93%⁴.  [Evidence level B]

In adults, the duration of symptoms is important in distinguishing a viral and bacterial aetiology because viral infections are self-limiting and usually have resolved or are improving within 10 days.  Worsening symptoms after 5 days of a common cold, after initial improvement, or persistent symptoms 10 days after onset associated with purulent nasal discharge².  [Evidence level B]

There are no clinical features that reliably distinguish between different types of pathogen or different species of bacterial pathogen.

Examination
Temperature and physiological observations (pulse, blood pressure, respiratory rate) should be measured in patients presenting to hospital.

Anterior rhinoscopy (with an auroscope) can confirm purulent nasal discharge.

Any facial swelling / erythema over the maxilla or frontal sinus should be noted. All but the sphenoidal sinuses can be palpated for tenderness:

-Frontal sinus - press upward beneath the medial side of the supraorbital ridge.
-Maxillary sinus - press against the anterior wall, below the inferior orbital margin.
-Ethmoidal sinus - press medially against the medial wall of the orbit.

Signs of orbital or intracranial complication should be excluded.

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A raised white cell count or CRP lends support to an infective aetiology but is neither sensitive nor specific. Recommendation: Baseline FBC and U&E for patients admitted to hospital for intravenous antimicrobial therapy. [Evidence level D]

Maxillary sinus puncture and culture of the aspirate provides optimal material for microbiological investigation and has therapeutic value. The invasive nature of this investigation and the recommended expertise required means that it is not as a routine for acute community-acquired sinusitis. Recommendation: Routine maxillary sinus puncture is not indicated but, whenever maxillary sinus puncture is undertaken by ENT surgeons, samples of pus should be sent for microbiological investigation. [Evidence level B]

Endoscopically-directed middle meatal pus sampling is less invasive than maxillary sinus puncture and can provide useful microbiological information. Recommendation: Endoscopically-directed middle meatal sampling is recommended for persisting or complicated sinusitis.^{1, 2} [Evidence level B]

Recommendation:  CT scanning of the paranasal sinuses with contrast is necessary when intracranial or orbital complications are suspected. ^{2, 7} [Evidence level A]

Recommendation: Routine radiographic imaging for patients with acute community-acquired rhinosinusitis is not recommended. ^{2, 7} [Evidence level A]

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Recommendation:  Simple analgesia should be given for symptom control or mild pain and fever⁷.  [Evidence level C].

Recommendation:  Topical intranasal steroids (mometasone furoate 50micrograms 2 sprays to each nostril every 12 hours) have successfully been used as monotherapy and also combined with antibiotics in the treatment of non severe acute bacterial rhinosinusitis. Treatment is continued for 10 days^{8, 9}. [Evidence level A]

Recommendation: Decongestant nasal drops (ephedrine 0.5% two drops to each nostril every 8 hours) may be administered to decrease congestion at the osteomeatal complex for 5 days, but evidence to support their efficacy is not available^{10, 11}. [Evidence level D]

Recommendation: Nasal douching with sinurinse (Neilmed) or a mixture of sodium and bicarbonate may help to remove purulent secretions¹². [Evidence level D]

Patients with sinus symptoms are frequently over-treated with antimicrobials⁵.  There is a general view that antimicrobial therapy should be reserved for patients with a high likelihood of bacterial infection according to diagnostic criteria outlined above. See Algorithm. Prior antimicrobial treatment and severity of illness are important considerations in the choice of antimicrobial therapy.

A recent systematic review of randomised controlled trials of treatment regimens for radiologically confirmed maxillary sinusitis in ambulatory patients found that antimicrobial therapy with Amoxicillin or penicillin was statistically associated with higher cure rates when compared to placebo^{7, 13-15}.  It is important to note that spontaneous improvement in symptoms occurred in a majority of cases, e.g. 77% of the placebo group.

The same systematic review found no difference in cure rates between penicillins and macrolides, quinolones, tetracyclines or cephalosporins. Similarly amoxicillin-clavulanate produced equivalent cure rates to cephalosporins and macrolides but with a worse side-effect profile.

It is noteworthy that a high proportion of patients in the placebo arms of these well-conducted trials had spontaneous resolution of their symptoms⁶.

The increasing prevalence of Clostridium difficile disease and meticillin-resistant Staphylococcus aureus infections means that cephalosporins and quinolones should not be used as first line agents where there is an effective, safe alternative.

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Recommendation: Acute rhinosinusitis in patients deemed well enough to be treated in the community may benefit from oral Amoxicillin 500mg 8-hourly for 10 days.  [Evidence level A].

Recommendation: Acute rhinosinusitis in ambulatory patients with a true penicillin allergy may benefit from Clarithromycin 500mg 12-hourly for 10 days¹³.  [Evidence level A].

There is a paucity of data pertaining to sinusitis, associated with sepsis, severe sepsis, septic shock and serious complications (cavernous sinus thrombosis, orbital cellulitis).  The severely ill patient with acute sinusitis may benefit from endoscopic middle meatal sampling or invasive sinus puncture to identify the pathogen followed by broad spectrum empirical antimicrobial cover². Among antimicrobials with the highest cure rates (90-92%) high-dose Co-amoxiclav  probably has a lowest risk of promoting colonisation/infection with healthcare associated pathogens than cephalosporins and quinolones.

Recommendation: Patients with symptoms/signs of rhinosinusitis who have severe infection (MEWS≥5) or judged to require IV inpatient therapy should be treated with Co-amoxiclav  1.2g 8-hourly iv pending microbiology results.  [Evidence level D]

Recommendation: Patients with a true penicillin allergy should be treated with 1st line Linezolid * 600mg 12-hourly PO/IV plus Ciprofloxacin 400mg 12-hourly iv plus Metronidazole 500mg 8-hourly iv
or 2nd line Teicoplanin * IV (see dosing guideline) plus Ciprofloxacin 400mg 12-hourly iv plus Metronidazole 500mg 8-hourly iv
[Evidence level D]

*Linezolid has a number of drug interactions/contraindications. Please see full guidance to check suitability for the patient. This is an off-label use of linezolid and Teicoplanin ; the patient should be informed of this.

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When middle meatal or sinus samples have been collected, review empirical antimicrobial therapy with culture results and amend to the most narrow spectrum antimicrobial available e.g. use Flucloxacillin for Staphylococcs aureus (meticillin susceptible strains), Amoxicillin /Benzyl penicillin for Streptococcus pneumoniae.  If in doubt contact microbiology for advice.

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Patients with acute community acquired bacterial sinusitis can be switched to oral antimicrobials as soon as they are clinically improving and fulfil criteria set out on the oral switch guideline.  Patients with complicated sinusitis are likely to need a longer duration of IV antimicrobials and this should be determined on a case-by-case-basis and in consultation with microbiology.

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