Table 1. General Management Principles and Adjunctive Treatment Recommendations for Patients with Upper Respiratory Tract Infections and Sinusitis*
   
� Appropriate prescribing and use of antibiotics will help reduce the development of antimicrobial drug resistance. Most Americans will encounter 4-6 upper respiratory tract infections per year. The overwhelming majority of these infections will resolve in 7-10 days without antibiotic treatment.
� Patients should be made aware that a typical cold begins with symptoms of itching, sneezing, and watery drainage. Fever and malaise are possible. After 3 or 4 days, the watery nasal drainage becomes thicker and often discolored. It begins to drain down the back of the throat and often results in a cough. The cough may linger beyond a week, even after the nasal symptoms have resolved.
� Antibiotic therapy may be prescribed if symptoms extend beyond a week, if symptoms are severe, or if patients have a compromised immune system.
� Although there is very little that patients can do to shorten the course of a common cold or symptoms of rhinosinusitis associated with a viral infection, there are several fundamental treatments available at home and over-the-counter to reduce symptoms during the acute phase of the illness.
� Many of the treatments described below are available in combination form. Because symptoms will occur at different times during the illness, patients may need to have several individual medications available rather than one combination treatment that is designed for symptoms that may not be present at any particular time during the infection.
 
Treatment options:
 
1. Rest, fluids, and good nutrition are critical to maintaining maximum immune function for combating any medical illness. Although there is limited evidence supporting the use of large doses of vitamins, it is very clear that vitamin and other nutritional deficiencies can significantly impair immune function.
2. Antihistamines are most commonly indicated for patients with allergies. These medications tend to dry nasal secretions and may suppress itching and sneezing during the first few days of upper respiratory tract infections. There are several brands available on the market. Loratadine and most of the prescription brands are less sedating than the older generic antihistamines.
3. Decongestants open the nasal passages so patients can breathe more freely and secretions can drain more easily. Topical decongestants like oxymetazoline and phenylephrine have a risk of rebound nasal congestion. They also can become habit forming if used for longer than five days. Pseudoephedrine is an oral decongestant that has less rebound potential, but does have a higher potential to raise blood pressure or cause urinary retention.
4. Guaifenesin is an expectorant used to promote increased nasal secretions. This will loosen thick nasal or bronchial secretions and allow better drainage. Guaifenesin is only effective if consumed with adequate amounts of water, usually at least two glasses of water with every meal.
5. Non-medicated nasal saline is available over-the-counter or can be mixed at home by adding one-half teaspoon of salt and one-half teaspoon of baking soda to 8 oz. of warm water. This may be sniffed or sprayed into the nose to dissolve and wash away germs and thickened sections. Nasal saline spray may be used liberally regardless of other medical conditions.
6. Cough suppressants usually contain dextromethorphan or another mild narcotic. These are not habit forming unless used in high doses for extended periods of time. Prolonged coughing could be an indication of a serious medical disorder. Coughing that persists for longer than two weeks should undergo more thorough evaluation.
7. Analgesics such as acetaminophen, ibuprofen, and naproxen can greatly reduce the aches and pains of a respiratory tract infection, reduce fever, and enhance a general sense of wellness. Some of these are combined with caffeine as an additional stimulant. Although these drugs are useful for helping patients accomplish what needs to be done during the day, patients should be counseled that plenty of rest, fluids, and good nutrition will strengthen host response more than any of these other symptomatic medications; and if symptoms are getting worse or are not improving after a week, patients should be reevaluated.
* Physicians are given permission to copy this table and use as patient education materials in appropriate settings.
  
  
Table 2. Triggers for Appropriate Use of Antibiotics in Patients without Comorbid Conditions Who Have Symptoms Consistent with Acute Rhinosinusitis
 

Initial antibiotic therapy is not recommended for patients with the following symptoms and presentations:1-3
  • Acute, mild, or moderate symptoms of rhinosinusitis for < 7 days duration
  • Symptoms limited to nasal drainage, rhinorrhea, or nasal congestion
  • Malaise in the absence of severe symptoms suggestive of rhinosinusitis
  • Non-specific, non-focal facial pain or pressure
  • Temperature < 101�
The following management approaches and symptom-directed therapy may be considered in the risk-stratified group described above (i.e., < 7 days duration of symptoms with no comorbid conditions)
  • Antipyretics
  • Analgesics (acetominophen)
  • Topical or systemic decongestants for a period of 3-5 days
  • For watery discharge, an oral or nasal anticholinergic (nasal ipatropium) may be considered for symptoms of vasomotor rhinitis
  • In patients with thick mucous production, consider use of thinning agent (saline spray or guaifenesin) and a decongestant to promote drainage, followed by an expectorant
  • In patients with a history of allergies or environmental allergies, topical nasal steroids should be considered as they may be helpful for reducing symptoms
Antibiotic therapy should be strongly considered in patients with some or all of the findings in the following severe-category symptom group suggestive of bacterial rhinosinusitis, regardless of duration
  • Temperature > 102�
  • Unilateral facial pain or pressure
  • Bilateral facial pain, which may suggest pan-sinusitis
  • Facial erythema
  • Swelling over the sinus
  • Maxillary teeth pain
  • Bimodal disease course

1 Patients with symptoms suggestive of rhinosinusitis who are not improving or worsening after 2 days may be considered for antibiotic therapy.
2 Stronger consideration for antibiotic therapy should be given in immunocompromised patients for symptoms of less than 7 days duration; clinical judgment should prevail in such cases, and earlier referral to ENT may be necessary.
3 The presence of comorbid conditions, recurrent rhinosinusitis, and/or an unusual or aggressive course may prompt consideration of early antibiotic therapy.
 
 
Table 3. Acute Bacterial Rhinosinusitis: Adult Treatment Guidelines (Otherwise Healthy Patients Without Comorbid Conditions with > 7 Days of Persistent Symptoms or < 7 days2 of Severe Symptoms1 Suggestive of Bacterial Rhinosinusitis)
 

First-Line Antibiotic Therapy7

Amoxicillin/clavulanate extended release 2000 mg/125 mg PO BID x 10 days3
 (Alternative: amoxicillin/clavulanate 500 mg/125 mg PO TID x 10 days)

OR

Amoxicillin 875 mg PO BID x 10-14 days4

OR

Azithromycin 500 mg PO QD x 3 days

First-Line Alternative Antibiotic Therapy

Moxifloxacin5,8 400 mg PO QD x 10 days (preferred fluoroquinolone)

OR

Levofloxacin5 500 mg PO QD x 10-14 days

OR

Clarithromycin 500 mg PO BID x 14 days

OR

Doxycycline 100 mg PO BID x 10-14 days6

1 One or more severe symptoms present for less than 7 days which may prompt early antibiotic therapy may include the following: temperature > 102�; unilateral facial pain or pressure; bilateral facial pain, which may suggest pan-sinusitis; facial erythema; swelling over the sinus; maxillary teeth pain; and/or bimodal disease course.

2 Stronger consideration for initiating prompt antibiotic therapy should be given in the case of immunocompromised patients with symptoms of fewer than 7 days duration; clinical judgment should prevail in such cases, and earlier referral to ENT may be necessary.

3 Other beta-lactam antibiotics also may be considered, among them: cefpodoxime, cefuroxime, loracarbef, and ceftibuten.

4 Because of increasing resistance to amoxicillin among S. pneumoniae isolates from patients with bacterial respiratory tract infections, high- dose amoxicillin therapy is recommended for treatment of acute bacterial rhinosinusitis in adults. In addition, amoxicillin also is preferred as an initial agent when acquisition of the antibiotic may be compromised by cost considerations, resulting in medication noncompliance.

5 Fluoroquinolones are effective and safe agents for the treatment of acute bacterial rhinosinusitis, and produce similar outcomes when evaluat ed against comparator agents. However, recent practice guidelines for bacterial respiratory tract infections from the Infectious Disease Society of America (IDSA) and Centers for Disease Control and Prevention (CDC) note that affecting positive outcomes with potent, excessively broad-spectrum agents must be balanced against the pitfalls of inducing resistance to such agents, especially fluoroquinolones. In its Dec. 1, 2003, Practice Update Guidelines for community-acquired pneumonia (CAP), the IDSA committee expressed concern about misuse and over use of fluoroquinolones, noting that if abuse of this class of drugs continues unabated, we may see the demise of fluoroquinolones as useful antibiotics within the next 5-10 years (Clin Infect Dis. 2003;37:1405-1433).

6 Doxycycline should be considered as an alternative agent when acquisition of the antibiotic may be compromised by cost considerations, resulting in medication noncompliance.

7 If a patient with presumed acute bacterial rhinosinusitis has received a previous course of antimicrobial therapy with either a beta-lactam (cefuroxime, amoxicillin, amoxicillin/clavulanate, etc.) or a macrolide within the past 3 months, excluding the current episode, a respiratory fluo roquinolone (i.e., moxifloxacin, levofloxacin) is recommended as the initial treatment. Conversely, recent use of a fluoroquinolone should dic tate use of either an advanced generation macrolide (azithromycin or clarithromycin) or a beta-lactam (amoxicillin/clavulanate).

8 Among the advanced generation, respiratory fluoroquinolones, moxifloxacin is preferred because it has lower MICs against S. pneumoniae than levofloxacin, and because it has a more narrow (gram-positive organism-focused) spectrum of coverage.

 
 

Table 4. Acute Bacterial Rhinosinusitis: Adult Treatment Guidelines for Special Populations (Patients with Comorbid Conditions, Infection with Drug-Resistant S. pneumoniae or Gram-Negative Organisms, Invasive Infection, and/or Immunosuppression)

 

First-Line Antibiotic Therapy

Moxifloxacin 400 mg PO QD x 10 days

OR

Levofloxacin 500 mg PO QD x 10-14 days

First-Line Alternative Antibiotic Therapy

Amoxicillin/clavulanate extended release 2000 mg/125 mg PO BID x 10 days1

(Alternative: amoxicillin/clavulanate 500 mg/125 mg PO TID x 10 days)
1 Other beta-lactam antibiotics also may be considered, among them: cefpodoxime, cefuroxime, loracarbef, and ceftibuten.