32 yo woman with sinusitis

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32 yo woman with sinusitis

• Started with runny nose, cough, and sore throat
  10 days ago
• Developed nasal congestion and drainage 1 day
  later
• On day 6 seen by PCP, with fever and above
  symptoms, started on azithromycin
• Now seeing you with persistent left sided facial
  pain and fever

2

• Exam 132/78, 92, 12, 100.8
• Tender to palpation in L maxillary area
• Otherwise normal

3
What would you do now?

• Sinus X ray
• Sinus CT
• Refer to ENT for sinus culture
• d) No further testing

4
What would you do now?

1. Stop antibiotics
2. Amoxicillin/clavulanate
3. Linezolid
4. Moxifloxacin

5
Sinusitis, bacterial more likely if

• Symptoms lasting for 10 days without evidence
  of clinical improvement
• Onset with severe symptoms or fever 102 F and
  purulent nasal discharge or facial pain lasting
  for at least 34 consecutive days
• Worsening symptoms (new onset of fever, headache,
  or increase in nasal discharge following a URI
  that was initially improving

6
Sinusitis, evaluation

• Good history and exam
• X ray and CT
• Very high rates of false positives in viral URI
• CT reasonable if surgery is planned or if
  complications occur (OM, CST)
• Referral to ENT reasonable in patients who are
  not improving on appropriate therapy or if
  suppurative complications occur

7
Sinusitis, treatment

• Amoxicillin-clavulanate is the preferred empiric
  regimen, for 5-7 days in adults (14 in children)
• Amoxicillin alone, macrolides, TMP/SMX, not
  recommended for initial empiric therapy
• FQ not recommended routinely due to cost and
  spectrum of activity
• In penicillin allergy doxycycline or FQ are
  options for empiric therapy
• No need to cover for MRSA routinely

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