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Acute Rhinosinusitis in Adults

Appropriate diagnosis and treatment practices in the emergency department

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Each year in the United States, approximately 2.7 million emergency department (ED) visits are related to colds and viral upper respiratory infections. Antibiotics are frequently prescribed in the ED to non-immunocompromised adults with viral illnesses, despite their lack of effectiveness against these complaints.1 According to the Centers for Disease Control and Prevention (CDC), antibiotic resistance is one of the world's largest health concerns. Frequent and inappropriate use of antibiotics increases drug-resistant bacteria and threatens medication usefulness. When antibiotics become unsuccessful, the length of illnesses increases, the number of office visits or hospital stays increases, and the need for expensive and possibly toxic medications rises.2 Astute attention to appropriate diagnosis and treatment will help minimize the overprescribing of antibiotics for upper respiratory viral infections.

Acute Viral Rhinosinusitis

Acute viral rhinosinusitis, also known as the common cold, is a benign self-limited illness representing variable degrees of upper respiratory symptoms caused by viral pathogens. In the United States, it is the leading cause of medical office visits and school and work absences.3 Numerous evidenced-based reports about treatment have been published, however, these reports suffer from inconsistent definitions of disease, differing measured symptom outcomes, mixing of subjective and objective findings, and variable age ranges.3

Rhinosinusitis can be classified in four categories: acute, with symptoms lasting up to 4 weeks; subacute, with symptoms lasting 4 to 12 weeks; recurrent acute, with four or more episodes yearly lasting at least 7 days and complete resolution between episodes; and chronic, with symptoms extending past 12 weeks.4

Symptoms of acute viral rhinosinusitis are typically due to an immune response from the causative viral pathogen. Clinical features vary among patients and may encompass rhinorrhea, difficulty breathing nasally, sinus inflammation, sneezing, sore throat, cough, headache, and fatigue. There are no prominent signs or symptoms with this illness. Fever is uncommon in adults with acute viral rhinosinusitis. Age, underlying disease and the type of infecting virus all contribute to the severity and nature of symptoms.3 Symptoms typically persist between 2 and 14 days, and they typically subside in 1 week to 10 days. Acute viral rhinosinusitis occurs in the fall and winter seasons because cooler air dries the nasal mucosa, making it more susceptible to viruses.5

Acute viral rhinosinusitis is the most common acute illness in the United States. The average adult experiences two to three episodes a year. More than 200 viral pathogens can cause acute viral rhinosinusitis.3 More than 100 viruses have been identified as distinct rhinovirus pathogens and they collectively cause approximately 30% to 50% of acute viral rhinosinusitis occurrences.5

The incubation period for the most common viruses causing acute viral rhinosinusitis is 24 to 72 hours, but symptoms can occur as early as 10 to 12 hours after exposure. Symptoms of acute viral rhinosinusitis are a result of an immune response to the viral pathogens. Purulent nasal discharge occurs both in patients with acute viral rhinosinusitis and patients with secondary bacterial rhinosinusitis. Therefore, purulence alone cannot distinguish between an infection that is viral or bacterial in nature.

Transmission of viruses usually occurs by direct contact or by small or large droplets.3 Rhinoviruses can live up to 3 hours on skin and up to 3 hours on objects such as countertops, telephones, remote controls, doorknobs and stair railings.6

The diagnosis of acute viral rhinosinusitis is based on presenting signs and symptoms. On physical examination, patients may exhibit a low-grade fever, nasal vocal tone, macerated skin over the nostrils, inflamed nasal mucosa, or an erythematous pharynx with exudate due to postnasal drip.7 Laboratory and radiologic studies are not diagnostically indicated. Possible differential diagnoses include allergic or seasonal rhinitis, bacterial pharyngitis or tonsillitis, acute bacterial rhinosinusitis, influenza, and pertussis.3 Patients should be fully examined for possible bacterial infections. A rapid test should be considered if influenza or bacterial pharyngitis is suspected. In the ED setting, identification of the viral pathogen causing acute viral rhinosinusitis is neither practical nor important.6

Prevention of acute viral rhinosinusitis is challenging. Most prevention strategies include hygienic measures such as hand washing, keeping hands away from mucus membranes, covering nose and mouth when sneezing or coughing, and avoiding droplet exposure. These are the simplest and best practices to avoid infection.6 Virus-killing disinfectant should be used to clean surfaces at home, in schools, in daycare settings and at work.5

Factors Influencing Antibiotic Prescriptions

Patient satisfaction ratings continue to be used as quality indicators and pay-for-performance measures for hospitals and clinicians. Patients who present to the ED with low-urgency illnesses, such as acute viral rhinosinusitis, have the lowest satisfaction rates with ED care compared to patients who present with more urgent needs. Clinicians have reported prescribing antibiotics to meet patient demands and expectations, and to minimize dissatisfaction rates for ED visits.1

Providers are frequently challenged to meet patient needs for desired symptomatic relief and rapid return to normal functioning. Patients may pressure clinicians and specifically ask for antibiotics, while some may request antibiotics more discreetly.

Conversely, clinicians may misinterpret patients' desires and assume they want antibiotics. When a patient describes symptoms as severe or mentions the need to get well quickly, providers may assume that antibiotics are being requested, thus resulting in patient-provider miscommunication. Moreover, writing a prescription indicates to the patient that the visit is over. Some physicians find that the quickest method to prevent lingering conversation when time constraints are significant is to prescribe an antibiotic. Diagnostic uncertainty also contributes to misuse, and antibiotics may be prescribed in case the nature of the illness is bacterial.8  

Despite this, there have been mixed reviews about the effects of antibiotic prescribing and patient satisfaction. Recent studies show that patient satisfaction is not increased by antibiotic prescriptions.8 Earlier studies found that patient requests for antibiotics to treat acute viral rhinosinusitis had decreased from 75% to 39% in the adult population.8 Factors that improve patient satisfaction include thorough physical exam, assurance of a confident diagnosis, caring behavior, and something concrete to show for their visit. This may include an over-the-counter medicine or a plan written on a prescription pad.8

Prevention of Antibiotic Misuse in the ED

The CDC's "Get Smart" campaign has contributed to a 25% reduction in antimicrobial prescribing at outpatient visits for presumed viral infections; intervention studies show a reduction of 8% to 26% for antibiotic prescriptions.2 Patient information guides are available online from various organizations and databases. These materials describe the causes of acute viral rhinosinusitis, signs and symptoms, appropriate treatment, complications, and prevention.

It is imperative to educate patients that antibiotics are used to cure bacterial infection and will not cure viral infections. Antibiotics do not prevent others from catching an illness, and they will not improve symptoms. The CDC recommends the following to increase patient satisfaction:2

  • validate the patient's symptoms and illness while offering reassurance
  • provide specific suggestions to treat the patient's symptoms; present a written prescription for symptom relief to increase the likelihood of adherence to treatment
  • explain what the patient can expect over the next few days and what to do if symptoms worsen
  • if patients insist on antibiotics, provide facts about viral infections and antibiotics, including adverse effects.2

Familiarity with practice guidelines correlates with guideline compliance and improvement in quality of care. Many studies use guideline familiarity or knowledge as outcomes to assess the effectiveness of educational interventions or as measures of the circulation of guidelines.9 Variance among clinician prescribing habits is common, which allows room for improvement by addressing reasons for variability. Education for individual providers about prescribing behaviors may motivate those with the highest rates of use to modify their treatment plans for acute viral rhinosinusitis.10

Numerous patient education materials are available online from the World Health Organization, CDC, UpToDate, the Mayo Clinic, and United States Department of Health and Human Services. Clinicians can provide materials to educate patients and decrease misconceptions about antibiotic prescribing. It is important to emphasize that the patient's immune system will fight the virus, and that there are multiple things he or she can do to feel better. Such measures consist of staying home to rest; no smoking and avoidance of secondhand smoke; increased fluids like water, fruit juices and clear soups; gargling a few times a day with warm salt water or using throat sprays or lozenges; and using a cool-mist humidifier to help keep nasal mucosa and pharynx moist.2

Current Guidelines

The mainstay of treatment for acute viral rhinosinusitis focuses on symptomatic relief. Hundreds of over-the-counter medications are available targeting acute viral rhinosinusitis symptoms. More than $2 billion is spent on these medication annually in the U.S.7 Over-the-counter remedies, including decongestants, antihistamines and cough suppressants, may offer symptomatic relief, however, they will not prevent or shorten the length of illness. Patients should be advised to take these medications as directed and to be watchful of common side effects, such as drowsiness, dizziness, insomnia or upset stomach.5

Analgesics & Antihistamines

Acetaminophen and nonsteroidal anti-inflammatory drugs are often necessary to relieve pain, reduce fever, get adequate rest and resume daily activities. Analgesic choice should be based on severity of pain, and if necessary, should be paired with an opioid.4 Antihistamines are typically used for their drying effects and to alleviate sneezing and rhinorrhea. However, their use should be limited due to sedating and over-drying effects of the eyes, nose and mouth. Due to these side effects, antihistamines should not be used alone for acute viral rhinosinusitis except in patients with chronic allergic rhinosinusitis.4

Antitussives, Expectorants, Decongestants

Patients with acute viral rhinosinusitis may experience a cough caused by nasal obstruction or postnasal drip. Guidelines from the American College of Chest Physicians recommend against the use of cough suppressants for cough associated with acute viral rhinosinusitis because of their variable efficacy.3 Expectorants are often used to thin mucus secretions and improve nasal drainage. Expectorants have demonstrated no improvement as an adjunct treatment for acute viral rhinosinusitis and due to limited trials, it is not recommended.4 Topical and oral decongestants reduce mucosal edema and improve aeration and nasal drainage. The use of topical decongestants should be limited to no more than 3 days because rhinitis medicamentosa can occur after 72 hours of use. Prolonged use may cause epistaxis, agitation and insomnia.3 Oral decongestants have systemic effects and should be used with caution in patients with stable hypertension, stable ischemic heart disease, diabetes mellitus, prostatic hypertrophy, and glaucoma.11

Intranasal Glucocorticoids, Saline Nasal Irrigation

Intranasal corticosteroids decrease edema and inflammation of the nasal mucosa, nasal turbinates and sinus ostia. They are minimally absorbed and have a low prevalence of sys­temic adverse effects.4 Saline nasal irrigation may be used to loosen mucus, soften nasal passage and improve mucociliary clearance. Studies documenting the benefits of saline irrigation are limited, but it is a safe and inexpensive option for patients seeking symptom relief.4

Zinc, Vitamins and Herbs

In the 1970s, zinc ions were reported to inhibit rhinovirus replication. Since then, numerous studies have examined the efficacy of zinc against acute viral rhinosinusitis. Recent reviews have found that increased zinc intake was correlated with a reduction in the duration and severity of symptoms. In 2009, the Food and Drug Administration issued a public health advisory on an over-the-counter zinc-containing intranasal product called Zicam. The FDA suggested against use of this product due to multiple reports of irreversible anosmia. Zinc sulfate syrup or lozenges have been better tolerated than some tablet forms; conversely, some experts recommend against zinc preparations due to uncertainty and known toxicities.3

Vitamins and herbs have no proven efficacy for acute viral rhinosinusitis but are commonly used. Echinacea is the most commonly used botanical in the United States. Trials have documented no benefits from echinacea for acute viral rhinosinusitis. Studies of vitamin C revealed no improvement after the onset of symptoms, but the vitamin has been proven effective in the prevention of acute viral rhinosinusitis along with vitamins D and E.3

Cough and sore throat may be relieved with ice chips, benzocaine spray, lozenges and use of a clean humidifier or cool mist vaporizer while sleeping. Ear pain may be comforted by placing a warm, moist cloth over the affected ear along with taking acetaminophen, ibuprofen or naproxen, if not contraindicated. Sinus pressure may be relieved or minimized by placing a warm compress over the nose and forehead and by inhaling steam from a hot shower.2

A Pivotal Role

Although the frequency of inappropriate treatment and antibiotic prescribing has declined, the U.S. remains one of the highest misusers of antibiotics due to nonadherence to treatment guidelines. Providers typically believe that prescribing antibiotics is appropriate. However, a significant percentage of all antibiotics are prescribed inappropriately. Increasing awareness of rising antimicrobial resistance and guidelines for the treatment of acute viral rhinosinusitis are key to combating antibiotic misuse.12 Nurse practitioners play a pivotal role by following current guidelines and implementing appropriate diagnosis and treatment in the adult patient with acute rhinosinusitis.

Theresa A. Vidrine is a family nurse practitioner at St. Joseph Express Care in Brenham, Texas. Deedra Harrington is an assistant professor in the School of Nursing at University of Louisiana at Lafayette.

References

1. Stearns CR, et al. Antibiotic prescriptions are associated with increased patient satisfaction with emergency department visits for acute respiratory tract infections. Acad Emerg Med. 2009;16(10):934-941.

2. Centers for Disease Control and Prevention. Get smart: Know when antibiotics work. http://www.cdc.gov/getsmart

3. Sexton DJ, McClain MT. The common cold in adults. UpToDate. Available with subscription at www.uptodate.com.

4. Aring AM, Chan MM. Acute rhinosinusitis in adults. Am Fam Physician. 2011;83(9):1057-1063.

5. National Institute of Health. Common Cold. http://www.niaid.nih.gov/topics/commoncold/Pages/default.aspx

6. Goroll A, Mully A. Management of the Common Cold. In: Primary Care Medicine Office Evaluation and Management of the Adult Client. 6th ed. Philadelphia: Lippincott; 2009: 408-411.

7. Mossad S. Upper respiratory tract infections. The Cleveland Clinic Foundation. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/

infectious-disease/upper-respiratory-tract-infection/

8. McKay E. Giving patients what they want. Are you overprescribing antibiotics? ADVANCE for NPs and PAs. http://nurse-practitioners-and-physician-assistants.advanceweb.com/Article/Giving-Patients-What-They-Want-2.aspx

9. Linder JA, et al. Self-reported familiarity with acute respiratory infection guidelines and antibiotic prescribing in primary care. Int J Qual Health Care. 2010;22(6):469-475.

10. Grover ML, et al. Acute respiratory tract infection: A practice examines its antibiotic prescribing habits. J Fam Pract. 2012;61(6): 330-335.

11. Agency for Healthcare Research and Quality. Acute rhinosinusitis in adults. http://www.guideline.gov/content.aspx?id=34408

12. McDonnell Norms Group. Antibiotic overuse: The influence of social norms. J Am Coll Surg. 2008;207(2):265-275.




     

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