ACUTE SINUSITIS: IS IT NECESSARY TO USE ANTIBIOTICS?

Varvara G, Sinjari B. Acute sinusitis: is it necessary to use antibiotics? International Journal of Infection. 2023;7(3):73-76

G. Varvara^* and B. Sinjari

Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara ‘Gabriele d’Annunzio’, Chieti, Italy.

*Correspondence to:
Giuseppe Varvara,
Department of Innovative Technologies in Medicine & Dentistry,
University of Chieti-Pescara ‘Gabriele d’Annunzio’,
66100 Chieti, Italy.
e-mail: gvarvara@unich.it

Received: 01 August, 2023 Accepted: 13 October, 2023

ISSN 1972-6945 [online] Copyright 2023 © by Biolife-publisher This publication and/or article is for individual use only and may not be further reproduced without written permission from the copyright holder. Unauthorized reproduction may result in financial and other penalties. Disclosure: all authors report no conflicts of interest relevant to this article.

ABSTRACT

Rhinosinusitis is an inflammatory disease of the nasal mucosa which is common in childhood and can present complications. Typical symptoms include purulent rhinorrhea, cough, fever, periorbital edema or pain, nasal obstruction, frontal pain, and reduction or loss of smell. Early treatment with antibiotics is avoided, but not in cases of viral or fungal infection. The clinical picture of the disease is classified according to its severity and is distinguished in mild, moderate, and severe forms. Usually the mild form is treated only with analgesic and decongestant drugs, while antibiotic therapy is used as soon as possible in the moderate or severe form, to avoid complications such as meningitis and brain abscess. Recent guidelines for the use of antibiotics recommend amoxicillin-clavulanate as the first-choice drug. High-risk subjects are those who live in polluted geographical areas, and hospitalized and immunosuppressed patients, who are more likely to experience bacterial infections resistant to penicillin. Amoxicillin clavulanate is effective on Streptococcus pneumoniae and has bactericidal action on Moraxella catarrhalis and Haemophilus influenzae, while the most widely used cephalosporins in the treatment of sinusitis are cefdinir, cefpodoxime and cefuroxime. Amoxicillin inactivates beta-lactamase-producing strains of H. influenzae. In general, antibiotics reduce bacterial load and reduce the secretion of proinflammatory cytokines. Viral sinusitis activates NF-kB and the MEK/ERK cascade required for viral multiplication. If NF-kB is inhibited, the production of inflammatory cytokines and chemokines is reduced.

KEYWORDS: Rhinosinusitis, acute sinusitis, inflammatory disease, antibiotics, Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae

INTRODUCTION

Rhinosinusitis is an inflammation of the mucosa of the nasal cavity and paranasal sinuses (1). It is a common pathology, especially in childhood and adolescence, which can lead to serious complications.  Sinusitis exacerbation is commonly accepted as a complication of upper respiratory tract infections (2).  It is estimated that the prevalence of sinusitis in the population is 5-10%, and probably the percentages are even higher if we consider that many sinusitis cases go unnoticed because rhinitis is treated promptly with antibiotic therapy before the infection manifests itself (3).

The fundamental principle in the treatment of acute sinusitis is the selection of patients who need antibiotic treatment. Antibiotics are frequently used without efficacy in sinusitis with viral etiopathogenesis, which constitutes the majority of sinusitis cases, while bacterial etiology represents 30% of cases (4).

When a common cold does not heal and if there is still purulent rhinorrhea, cough with nocturnal exacerbation, fever, oedema, or periorbital pain after 10 days, rhinosinusitis should be considered (5). The association of clinical signs is the best indicator of bacterial infection. Among these, we must remember the “Clinical Practice Guidelines for acute bacterial rhinosinusitis” which establishes as diagnostic criteria: sudden onset of two or more characteristic symptoms (purulent rhinorrhoea and/or nasal obstruction), frontal pain, and reduction or loss of smell (6). Antibiotic treatment of sinusitis uses the same antibiotics used in the treatment of acute otitis media, given the common etiopathogenesis of the two infectious diseases (7).

When acute sinusitis is caused by bacterial infection, antibiotics are necessary, while in viral infections, antibiotics are useless. Antibiotics act as bactericidal and bacteriostatic agents, and the most widely used for bacterial sinusitis are amoxicillin, amoxicillin plus clavulanate (in combination), and doxycycline (8). Antibiotics reduce the bacterial load by fighting the infection and reducing inflammation.

DISCUSSION

The most recent recommendations of the “American Academy of Otolaryngology-Head and Neck Surgery Foundation” distinguish patients based on the severity of the clinical picture (6). In subjects with mild forms of rhinosinusitis, with moderate pain and T < 38.3° C, the “watchful waiting” strategy should be applied. In subjects with severe forms, with moderate to severe pain and T > 38.3°C, antibiotic treatment should be started. The “watchful waiting” strategy consists in postponing antibiotic treatment by 4-5 days because 60% of sinusitis cases resolve spontaneously and only one in eight subjects treated with antibiotics benefits from it (6). During the waiting period, it is recommended to use symptomatic drugs such as analgesics, decongestants, or saline nasal spray, which could promote drainage of the congested sinuses (9).

If the symptoms persist beyond the waiting period, antibiotic treatment should be started. In severe forms, antibiotic treatment is performed immediately to avoid the onset of complications and sequelae of sinusitis, such as meningitis, brain abscess, cellulitis, and orbital abscesses, which occur more frequently in the severe form. The most prescribed antibiotics vary in different geographical areas, but the most recent guidelines recommend amoxicillin-clavulanate at a standard dosage of 40 mg/kg/day as the first-choice drug in low-risk subjects, and a high dosage of 90 mg/kg/day in high-risk subjects (8). High-risk subjects are defined as those who live in geographical areas with a high incidence of penicillin-resistant strains of Streptococcus pneumoniae (>10%), those who have recently undergone antibiotic therapy, those who have recently been hospitalized, those under 2 years of age, and the immunocompromised (10).

The duration of treatment with amoxicillin clavulanate at both doses is 10-14 days and the dose is divided into 2 daily administrations. The choice of amoxicillin clavulanate is justified by its high efficacy on S. pneumoniae and its bactericidal action on the other pathogens causing sinusitis, Moraxella catarrhalis and Haemophilus influenzae, as well as by its good palatability and low-cost (11). The use of cotrimoxazole, macrolides, or second and third generation cephalosporins is not recommended due to the presence of high levels of resistance of S. pneumoniae to these antibiotics (12).

In subjects allergic to penicillins, the choice of antibiotic is conditioned by the type of hypersensitivity: in type I hypersensitivity reactions, the use of levofloxacin is recommended, and third generation cephalosporins and clindamycin are recommended in other types (13). The cephalosporins most used in the treatment of sinusitis are cefdinir, cefpodoxime, and cefuroxime (11). Among these, cefpodoxime, a third-generation cephalosporin, has a tolerability and efficacy equivalent to amoxicillin, but poor palatability. However, its use is advantageous with regard to the number of daily administrations (1 or 2 times a day) (14). Similar to cefpodoxime, cefdinir has good efficacy, good tolerability, and is administered twice daily, but is preferred because it has good palatability.

Finally, cefuroxime is a second-generation cephalosporin that is active against both penicillin-sensitive strains of S. pneumoniae and beta-lactamase-producing organisms, has good efficacy and good tolerability, but poor palatability (15). It is the only cephalosporin that can be used in short-term treatments (5 days). Treatment failure may be caused by infection with resistant pathogens, non-infectious or viral etiology of sinusitis, underlying anatomic abnormalities, inappropriate treatment, and patient non-compliance (16).

Persistent infection often occurs in sinusitis caused by beta-lactamase-producing strains of H. influenzae, against which amoxicillin is inactive (17). In cases of treatment failure in subjects treated with standard doses of amoxicillin-clavulanate, sinus aspirate culture is recommended, which allows for targeted antibiotic treatment (18).

Infections are fought by the immune system, which generates cytokines and chemokines, highly inflammatory proteins that increase vascular permeability and attract immune cells to the site of infection (19). Viral and bacterial infection stimulate the production of inflammatory cytokines (20,21).

Viruses infect host cells and replicate, which is recognized by host cells that secrete protective immune proteins of both innate and adaptive types (19). For example, the influenza virus activates NF-kB and the MEK/ERK cascade is required for viral multiplication (22). If NF-kB is inhibited, viral replication is blocked, along with the production of proinflammatory cytokines such as interleukin (IL)-1, tumor necrosis factor (TNF), interferon (IFN)-g, and IL-6 (23). Chemokines are also inhibited, including IL-8, MCP-1, RANTES, amongst others. These procedures may be useful for viral therapy (24). In regards to antibiotic therapy, it is important to control viral infection, which can develop into secondary bacterial infection.

CONCLUSIONS

In acute sinusitis with inflammation of the sinuses, antibiotics can only be effective against bacterial infections. The choice of antibiotic use must be made based on a correct diagnosis and the type of individual being treated.

Conflict of interest

The authors declare that they have no conflict of interest.

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