A 38-year-old woman with a history of hypertension comes to the physician with complaints of left-sided facial pressure, nasal congestion, and rhinorrhea for the past 5 days. She describes the rhinorrhea as yellow with occasional white, nonbloody, and thin discharge. She also notes fullness of the left ear. She has no fevers, chills, cough, wheezing, or muscle pain and has no known sick contacts.
Her temperature is 37.0 C (98.6 F), blood pressure is 114/74 mm Hg, pulse is 86/min, and respirations are 14/min. Oxygen saturation is 97% on room air pulse oximetry. Pupils are equal and reactive. There is mild tenderness over the right maxillary sinus. Nasal mucosa is boggy appearing and erythematous bilaterally. Her oropharynx is mildly erythematous without cervical lymphadenopathy. Lungs are clear to auscultation bilaterally.
Which of the following is the most appropriate empiric therapy for this patient?

Question

A 38-year-old woman with a history of hypertension comes to the physician with complaints of left-sided facial pressure, nasal congestion, and rhinorrhea for the past 5 days.  She describes the rhinorrhea as yellow with occasional white, nonbloody, and thin discharge.  She also notes fullness of the left ear.  She has no fevers, chills, cough, wheezing, or muscle pain and has no known sick contacts.
Her temperature is 37.0 C (98.6 F), blood pressure is 114/74 mm Hg, pulse is 86/min, and respirations are 14/min.  Oxygen saturation is 97% on room air pulse oximetry.  Pupils are equal and reactive.  There is mild tenderness over the right maxillary sinus.  Nasal mucosa is boggy appearing and erythematous bilaterally.  Her oropharynx is mildly erythematous without cervical lymphadenopathy.  Lungs are clear to auscultation bilaterally.
Which of the following is the most appropriate empiric therapy for this patient?

Quizplus · Accepted Answer

11ec193a_979c_b596_853d_a7a364313b20_MD0002_00 This patient's presentation of 5 days of yellow rhinorrhea, nasal congestion, and facial pressure is consistent with acute viral rhinosinusitis. Most acute sinusitis in primary care is viral and associated with the common cold. It is important yet difficult to differentiate viral rhinosinusitis (AVR) from acute bacterial rhinosinusitis (ABR) as AVR does not require antimicrobial therapy but ABR does. ABR is more likely in patients with symptoms for > 10 days, severe symptoms (eg, fever plus sinus tenderness or facial pain) for > 3 days, or worsening symptoms > 5 days after an initially improving viral upper respiratory infection. This patient meets no ABR criteria and can receive supportive care (eg, analgesics, saline irrigation, topical decongestants, and/or topical glucocorticoids). If her symptoms worsen or last > 10 days, she may have ABR and then would require antibiotic treatment. Current guidelines recommend 5-7 days of amoxicillin-clavulanate for ABR in non-penicillin-allergic patients (Choice A). Doxycycline and respiratory quinolones (eg, levofloxacin and moxifloxacin) are alternate agents for penicillin-allergic patients (Choice B). Amoxicillin, trimethoprim-sulfamethoxazole, and second- or third-generation cephalosporins are not recommended due to increased resistance in respiratory pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis (Choice E). (Choice C) Oseltamivir is a neuraminidase inhibitor that treats influenza. Patients typically present with upper respiratory infection symptoms, fever, headache, myalgia, and weakness. This patient's absence of myalgias and weakness make this less likely. In addition, antiviral therapy given after the first 48 hours of symptom onset is unlikely to be of much benefit. Educational objective: Acute rhinosinusitis is usually viral and is routinely treated with supportive care. Acute bacterial rhinosinusitis is more likely in patients with symptoms for > 10 days, severe symptoms (eg, fever plus sinus tenderness or facial pain) for > 3 days, or worsening symptoms > 5 days after an initially improving viral upper respiratory infection. __________ References: IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. (http://www.ncbi.nlm.nih.gov/pubmed/22438350)

A 38-Year-Old Woman with a History of Hypertension Comes to the Physician