A specimen culture would make a definitive case for or against antibiotic treatment, but in actuality, this is not done in most cases. Antibiotic therapy is incidental to the improvement of most cases of sinusitis, since the majority of cases are viral, said Dr. Ferguson.
Explore This IssueMay 2008
Martin Citardi, MD, of the Cleveland Clinic, said that an accurate diagnosis, including assessment of symptom severity and duration, should lead to treatment that is customized for each patient. Before prescribing either antibiotics or topical corticosteroids, comorbidities, such as lung disease, must be considered. The physician should probe for a history of multiple upper respiratory infections. Dr. Ferguson, whose area of expertise is in allergy management and sinonasal disorders, emphasized that the practitioner should take allergies into account. It is also crucial to determine which other drugs the patient is taking, especially Coumadin.
While taking a conservative view of antibiotic use, Dr. Citardi also warned against excessive caution when a bacterial cause may be likely. The much-publicized growth of drug-resistant bacteria seems to have plateaued, he said.
When to Consider Steroids
Whether or not antibiotics are employed, this is the point where the physician may consider topical corticosteroid therapy. Stilianos Kountakis, MD, Professor of Otolaryngology at the Medical College of Georgia, believes they are a good shotgun treatment, because of their safety. The medications are not absorbed in significant amounts, and there is no problem of immunosuppression, said Dr. Kountakis. He would not, however, prescribe oral corticosteroids for acute bacterial rhinosinusitis unless the patient is a few days into an effective antibiotic regimen to avoid immunosuppression.
Dr. Citardi pointed out that the sprays are beneficial on several levels. First, of course, they are anti-inflammatory, reducing the edema that causes the discomfort of rhinosinusitis. These complex drugs also may affect ciliary function. Even the preservatives in most steroidal nasal sprays may be useful as antibacterial agents.
If topical corticosteroids are to be prescribed, the clinician may wonder: which one? In the reviewed studies and in interviews with experts, there was no preference shown. Although the drugs differ from each other pharmacologically, their benefits are almost identical. Even though some insurers may insist that generic fluticasone propionate be prescribed, there is no real therapeutic-or economic-difference between it and the proprietary drugs.
In the rare cases in which morbidity progresses to the chronic stage, or if nasal polyps develop, topical corticosteroids should be tried, but this is not an FDA-approved treatment for these conditions. Fungal complication is another area beyond the scope of the studies. Dr. Marple said that these conditions may differ fundamentally from acute rhinosinusitis.