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

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

What would you do now?

a) Sinus X rayb) Sinus CTc) Refer to ENT for sinus cultured) No further testing

What would you do now?

a) Stop antibioticsb) Amoxicillin/clavulanatec) Linezolidd) Moxifloxacin

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 3–4 consecutive days

• Worsening symptoms (new onset of fever, headache, or increase in nasal discharge following a URI that was initially improving

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

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