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November 25, 2020 09:00pm
By Sara Karlovitch, Assistant Editor
Acute respiratory infections are among the most common reasons why patients in the United States seek medical care.
Acute respiratory infections—specifically rhinosinusitis (RS), bronchitis, and pharyngitis—are among the most common reasons why patients in the United States seek medical care. With acute respiratory infections accounting for approximately 60% of all retail clinic,1nurse practitioners and physician assistants play a key role in diagnosing these illnesses and treating these patients. This article presents an overview and case study of RS and discusses its management in the retail clinic.
Acute Rhinosinusitis Overview
RS affects approximately 14% of the US population.2According to a recent analysis of National Health Interview Survey data, RS caused a similar number of missed workdays as acute asthma.3In the literature, the term “rhinosinusitis” is used synonymously with “sinusitis”; however, RS is a more appropriate term because the nasal middle turbinate extends directly into the ethmoid sinuses, and sinus inflammation rarely occurs without concomitant inflammation of the contiguous nasal mucosa. The subtypes of RS are acute RS (viral or bacterial), chronic RS with and without nasal polyps, and allergic fungal RS.
Acute RS is most commonly viral, with an average frequency of 8 to 10 times per year in children and 2 to 5 times per year in adults. In the current climate of antibiotic stewardship, the judicious use of antibiotics has come into sharp focus because of patients’ growing resistance to commonly used antibiotics. Although the impression is much higher, bacterial infections complicate viral RS in less than 3% of cases.
Antibiotics are prescribed for 80% to 90% of acute respiratory infection cases, even though 60% of cases resolve on their own.2It is theorized that the overuse of antibiotics is linked to the underdiagnosis of allergic or viral infections. This topic has gained national attention as an area of necessary education for health care providers.
During the past decade, a number of expert panels—including the Joint Task Force (consisting of members from the American Academy of Allergy, Asthma, & Immunology; American College of Allergy Asthma and Immunology; and Joint Council of Allergy, Asthma, and Immunology) and the American Academy of Otolaryngology-Head and Neck Surgery Foundation—have put forth evidence-based guidelines for the diagnosis and management of RS. Although the guidelines have distinct yet subtle differences, they are comparable in the guidance they offer health care providers.
Acute Rhinosinusitis Case Study
Felicia is a 31-year-old graduate student who presents to the retail clinic with a 2-day history of congestion, colored nasal discharge, headache, sneezing, and overall fatigue. She is taking acetaminophen for her headache and has no significant medical history or known drug allergies. She does not take any medicines regularly except multivitamins and a calcium supplement. Felicia’s final exams start in 12 days, and she feels that a course of antibiotics will help her recover more quickly.
DISCUSSION QUESTION:What additional information would you want to know about Felicia’s history and current illness?
ANSWER:Additional questions to aid the diagnostic process include whether Felicia has had any recent viral or bacterial exposures, if she has any past medical history of environmental allergies, if there is any repeated pattern of similar presentations, or if she has taken any medications to remedy symptoms.
Acute RS is a clinical diagnosis, and understanding its presentation is important in differentiating its etiology as viral, bacterial, or allergic. No specific diagnostic tests or absolute clinical signs or symptoms for acute RS exist, so the overall clinical impression should be used to guide diagnosis and management.
Acute viral RS symptoms typically peak within 2 to 3 days of onset, decline gradually, and disappear within 10 to 14 days. Symptoms that persist for 10 or more days, support a pattern of initial improvement followed by worsening, or include unilateral facial or tooth pain suggest acute bacterial RS.2It is a myth that the presence of fever or the color of nasal mucus alone can distinguish between viral and bacterial etiologies. Although the sole presentation of purulence cannot differentiate between viral and bacterial infection, a diagnosis of acute bacterial RS is unlikely in its absence.
After taking a thorough history, you begin your examination of Felicia and find pale, boggy nasal turbinates; scant purulent mucus discharge; a slightly erythematous oropharynx; and postnasal drip. All other findings are normal.
DISCUSSION QUESTION:What is your initial diagnosis for Felicia’s presentation?
ANSWER:Based on Felicia’s history and exam, she is diagnosed with acute viral RS. A viral RS disease process involves 2 steps, the first of which is a viral infection of the nasal cells and the second of which is activation of inflammatory mediators that directly cause symptoms.
Treatment options you initially consider for Felicia include the following:
• First-generation antihistamines
• Nonsteroidal anti-inflammatory drugs
• Oral decongestants
• Intranasal decongestants (patients should avoid using topical decongestants for more than 3 days to reduce the likelihood of rebound congestion)
• Cough suppressants
• Intranasal anticholinergics
• Intranasal corticosteroids (the only intranasal corticosteroid currently indicated for the treatment of RS is mometasone furoate)
• Nasal saline rinse
• Complementary medications such as zinc, echinacea, and vitamin C
DISCUSSION QUESTION:What key educational messages would you share with Felicia regarding treatment?
ANSWER:The best strategy for treating acute viral RS is to start treatment as soon as symptoms present (the first 3 days are the most important) and to continue it until symptoms resolve (7 to 10 days on average). The suggestion for prompt and continuous treatment is based on the known timeline of viral courses from the nasal passages into the sinuses. Acute viral RS symptoms may appear as early as 10 hours after inoculation and may increase in severity for 48 to 72 hours, after which symptoms usually begin to dissipate in keeping with the natural course of the virus.
Felicia returns 10 days later and presents with worsening nasal congestion and drainage, unilateral facial pain, worsening headache, increased purulent nasal drainage, and fever. Upon exam, you find that Felicia has bilateral erythematous and inflamed turbinates, copious purulent drainage, and right frontal/maxillary sinus tenderness. The remainder of her exam is unremarkable.
DISCUSSION QUESTION:What is your new diagnosis for Felicia?
ANSWER:Felicia is now diagnosed with acute bacterial RS. When considering whether further workup would be of value, all guidelines agree that plain radiography (eg, Waters’ view) is not useful or cost-effective. Computed tomography is not typically recommended for routine evaluation but is the imaging method of choice should it be warranted. Nasal cultures are not recommended for routine workup. Sinus puncture is a standard method for confirming bacterial pathogens in maxillary sinuses, but it is costly, inconvenient, and uncomfortable for the patient. Nasal endoscopy is reserved for pharmacotherapy failure.
The treatment goal for bacterial RS is to address the likely causative bacterial pathogens, such asStreptococcus pneumoniae,Haemophilus influenzae, orMoraxella catarrhalis. Nurse practitioners and physician assistants should be aware of the probability of bacterial resistance within their community. Typically, the state health department is a resource for information on antibiotic resistance within a metropolitan or rural health area.
Multiple factors should be considered when choosing an antibiotic for treatment, including the likely causative organisms, given the clinical picture, and likelihood of resistant strains within a community. If amoxicillin is chosen, it should be given at double the standard dose (eg, 80 mg/kg/day to 90 mg/kg/day), especially in areas with knownS. pneumoniaeresistance. The course of treatment is usually 10 to 14 days. Of note, the Infectious Diseases Society of America recommends amoxicillin/clavulanate over amoxicillin alone as empiric antibiotic therapy in children and adults with acute bacterial RS.4
In patients who are allergic to penicillin, the first-line therapy is a macrolide antibiotic because of its low cost, ease of administration, and low toxicity. If patients reside in a locality with a high incidence of resistant organisms or fail to show initial improvement in symptoms within 72 hours of starting an antibiotic, consideration should be given to prescribing a second-line antibiotic such as a cephalosporin or quinolone.
DISCUSSION QUESTION:What key educational messages would you share with Felicia regarding symptomatic care of her acute bacterial RS?
ANSWER:In addition to adhering to the prescribed antibiotic treatment, options for symptomatic care may include the following:
• Warm compresses to address facial pain
• Adequate hydration
• Adequate rest
• Nasal irrigation
• Balanced nutrition
• Non-narcotic analgesia
Acute RS is among the most prevailing reasons patients seek medical care, and many of those visits occur in the retail clinic setting. Far too frequently, health care providers misdiagnose viral or allergic RS as a bacterial illness—a misstep that is believed to contribute to the overprescribing of antibiotics.
In this case, Felicia was initially diagnosed with acute viral RS. After being given appropriate viral treatment, her symptoms worsened. Felicia was diagnosed subsequently with bacterial RS and treated with a course of amoxicillin/clavulanate for 10 days.
Although patients like Felicia who present to the retail clinic with acute viral RS may expect to be prescribed an antibiotic, the time invested in patient education about appropriate viral treatment, the typical course of the disease, and antibiotic stewardship will go a long way toward improving their health outcomes.
Karen Rance, DNP, APRN, CPNP, AE-C,is an allergy, asthma, and immunology specialty nurse practitioner. She is a medical science liaison with Meda Pharmaceuticals and an adjunct faculty member at Indiana Wesleyan University Graduate School of Nursing. Dr. Rance has served on the board of directors of the National Association of Certified Asthma Educators and is on the National Heart, Lung, and Blood Institute’s National Asthma Education Prevention Program Expert Panel workgroup. She is the founding chair of the National Association of Pediatric Nurse Practitioners’ (NAPNAP) Asthma and Allergy Special Interest Group and is on NAPNAP’s Clinical Expert Panel for Asthma.