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CANADIAN GUIDELINE FOR ACUTE BACTERIAL RHINOSINUSITIS

Ruchmana Aga 112013319Lia Trisna Pertiwi 1320221146

DEFINITION Rhinosinusitis is the inflammation of the

nasal passages and sinus cavities. It causes a combination of symptoms of rhinitis and sinusitis

Usually, rhinosinusitis caused by allergies or an infection

EPIDEMYOLOGY Rhinosinusitis is a common malady, afflicting

approximately 1 in 8 adults

America 11% (26 million) in 2007 to 13% (29.8 million) in 2010

Canada 3.5 million adults with acute rhinosinusitis annually

SinusitisEtiologic Organisms (& % incidence)

Bakteri Aerob:• Strep. pneumoniae (30%)• Hemophilus influenzae (25 to 30%• Moraxella catarrhalis (15 to 20%)• Alpha & beta hemolytic Strep (5%)• Staph. aureus (5%)• Escherichia coli (5%)

RADIOLOGY Axial image showing mucosal thicknening and an air-fluid level in the maxillary sinus (MS)

Bakteri Anerobes (10 % acute, 66 % chronic)

Peptostreptococcus,Propionobacterium, Bacteroides, FusobacteriumFungi (2 to 5%)Viruses (5 to 10%)

Acute Sinusitis Predisposing Conditions

Local–Allergic rhinitis–Nasal septal defects–Barotrauma (diving)–Nasal foreign bodies–Dental infections–Over use of topical decongestants–Nasal polyps or tumors–Aspiration of infected water–Smoking

Acute Sinusitis Predisposing Conditions

Systemic :–Diabetes–Immunocompromise (AIDS)–Malnutrition–Chemotherapy–Long term steroid Rx

CLASSIFICATION

By the duration of an inflammatory episode

Acute (up to 4 weeks) Subacute (4–12 weeks) Chronic (> 12 weeks) Recurrent acute rhinosinusitis ( ≥ four episodes

per year without evidence of chronic rhinosinusitis)

7-14 days to 1 month of symptoms

Infectious etiology Viral Bacterial

Symptoms:Purulent nasal drainage +

facial pain / pressure + nasal obstruction

>12 weeks

Etiology: Often not infectious, however bacterial profile differs from acute , culture-directed antimicrobial therapy is essential, can also be fungal

Symptoms: Chronic Purulent nasal drainage + facial pain/pressure + nasal obstruction + hyposmia

Acute Rhinosinusitis

Chronic Rhinosinusitis

DIAGNOSIS

P : Facial Pain, pressure/fullness

O : Nasal Obstruction D : Nasal purulence /

discoloured postnasal Discharge

S : Hyposmia or anosmia (Smell)

• Headache• Halitosis• Fatigue• Dental pain• Cough• Ear pain or pressure

Major Symptoms Minor Symptomps

TREATMENT The goal of therapy : improve symptoms by

- controlling infection,- reducing edema- reversing sinus ostial obstruction

Guidelines recommend using disease severity to help direct therapy.

Severity is based on the duration and intensity of symptoms, coupled with the effect of the disease on patient quality of life

TREATMENT For mild to moderate ABRS

- intranasal corticosteroids (INCSs) can be used to reducing inflammation

In a clinical study, mometasone furoate for 15 days significantly improved symptoms scores, beginning at day 2, compared with amoxicillin for 10 days (P = .002) or placebo (P < .001)

Compared with placebo treatment, mometasone furoate was associated with significantly improved quality of life for patients with ABRS

THE EFFICACY OF INCSS USED WITH ANTIBIOTIC SIGNIFICANT BENEFIT OF 15 TO 21 DAYS OF INCS THERAPY ADDED TO

ANTIBIOTIC IN PATIENTS WITH ABRS

patients with moderate to severe ABRS who receivedamoxicillin-

clavulanate plus mometasone

furoatereported significantly improved

symptom scores (days 1 to 15 averaged) versus

patients taking antibiotic monotherapy (P ≤ .017)

patients with ABRS and history of recurrent sinusitis or chronic rhinitis, patients receiving cefuroxime axetil plus fluticasone propionate spray reported significantly

higher rate of clinical success (93.5% vs 73.9%, P = .009) and shorter duration

of symptoms (6 days to clinical success vs 9.5 days,

P < .01)

ANTIBIOTICS First line: Amoxicillin; for ß-lactam allergy use

TMP-SMX combinations or a macrolide

Second line: Fluoroquinolones or amoxicillin–clavulanic acid combinations use with first-line failures and in patients for whom the

risk of bacterial resistance is high or consequences of therapy failure are

greatest Bacterial resistance should be considered when selecting

therapy

ADJUNCT THERAPY Although clinical trial evidence is sparse for

adjunct therapies in the treatment of ABRS, these therapies might help alleviate symptoms associated with ABRS

Analgesic Decongestant (oral & topikal) Saline

FOLLOW UPIf failure

occurs after a second course of antibiotic therapy, specialist assessment is warranted

When to refer No response to second-line

therapy Suspected chronicity Persistent severe symptoms More than 3 recurrences per year Immunocompromised host Allergic rhinitis evaluation for

immunotherapy Anatomic defects causing

obstruction infection or neoplasms

CONCLUSION The Canadian guidelines provide up-to-date

recommendations for diagnosis and treatment of ABRS that reflect an evolving understanding of the disease

Although lacking in specificity, using duration-based symptoms for the diagnosis of uncomplicated cases of ABRS is the best available approach for diagnosis in the office setting

Intranasal corticosteroids have emerged as modestly beneficial as adjunct therapy or as monotherapy, with antibiotics reserved for severe cases of disease in otherwise healthy adults

TERIMA KASIH