Raj Sindwani, MD
- Specific data regarding sinusitis pathogens unavailable, but not expected to be different than typical causes outlined in module below.
S. pneumoniae is likely the prime pathogen in many HIV+ patients.
Zambia Information Author: Paul Auwaerter, M.D.
- Bacterial: Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenza, Pseudomonas aeruginosa, Staphylococcus aureus
- Fungal: Aspergillus fumigatus, Cryptococcus neoformans, Pseudallescheria boydii, Zygomycetes
- Other (rare): Mycobacteria, Nocardia spp., CMV, , microsporidia
- Prevalence: up to 68% in HIV+ population
- Maxillary and ethmoid sinuses most frequently involved; high incidence of sphenoid disease (2x general population)
- Mucociliary dysfunction plays important role: ciliary transport time is significantly prolonged, especially with CD4 <200
- Increased atopy (due to polyclonal B cell activation producing excessive IgE) produces new/increased allergic symptoms leading to nasal congestion and ostia obstruction
- History: nasal drainage, congestion, fever, headache, facial pressure/pain
- PE: fever, mucopurulent nasal or posterior pharyngeal drainage, mucosal congestion. Ominous findings include mucosal ischemia/necrosis, cranial nerve deficits, parathesias, proptosis, or meningeal symptoms: suggestive of invasive fungal sinusitis or malignancy. Also consider malignancy.
- Incidence of atypical infections, fungal sinusitis, NHL, KS increase with CD4 <150
- Acute bacterial sinusitis usually a clinical Dx based on Sx +/- anterior rhinoscopy.
- Nasal endoscopy: consider if discharge from middle meatus or sphenoid-ethmoid recess, refractory disease after initial ABx, or mucosal pallor or necrosis suggestive of invasive fungal infection
- Transnasal Cx (bacterial, fungal, AFB) and Bx for histopathology with special stains recommended for unusual pathogens, or consider antral tap for diagnostic Dx and therapeutic lavage if refractory to ABx or CD4 <200
- Sinus CT: indicated if fever or headache of unknown origin, persistent findings after appropriate therapy, possible complications or spread of infection
- MRI: indicated for fungal disease or to evaluate intracranial or orbital involvement
- Typical acute and chronic sinusitis: may be treated (initially) as in general population
- Acute sinusitis: amoxicillin 500 mg PO 3 times daily reasonable choice for uncomplicated cases (CD4 >200). Other choices include amoxicillin-clavulanate 875 mg PO twice-daily or cefuroxime 250 mg PO twice-daily.Treat for min. 10-14 days. If unresponsive to therapy after 3-4 days or CD4 <200 consider endoscopic Cx vs broadening coverage with clindamycin 300 mg PO 3 times daily (anaerobes) or levofloxacin 500 mg PO once-daily (gram negatives, P. aeruginosa).
- Chronic sinusitis (persistent Sx >12 wks): 6 wks Abx therapy with fluoroquinolone recommended, get endoscopically guided Cx
- Chronic resistant sinusitis: IV therapy such as anti-pseudomonal PCN or 3rd generation cephalosporin with aminoglycoside or quinolone
- Prophylaxis: TMP-SMX prophylaxis reduces occurrence of bacterial sinusitis in HIV+ pts
- Fungal sinusitis: empiric amphotericin B (1.0-1.5 mg/kg/d IV) for invasive and non-invasive infection plus surgical debridement pending identification
- Cx-based treatment for complicated, refractory, chronic or suspected fungal disease.
- Systemic decongestant therapy: OTC decongestants may provide some symptomatic relief.
- Topical nasal decongestant therapy: oxymetazoline (Afrin, Dristan) or phenylephrine (Neo-Synephrine, Sinex) 2-3 sprays per nostril twice-daily x 3 days only to avoid rhinitis medicamentosa
- Nasal steroid sprays may help chronic symptoms
- Consider antihistamine (with or without decongestant combination) if concomitant allergic rhinitis, second generation less sedating: fexofenadine, loratidine, cirtirizine
- Mucolytics: guaifenesin 100-400 mg PO q4hrs
- Saline irrigations using forceful flow of irrigant through nasal passages useful to clear debris and restore mucosal health
- Fungal sinusitis requires aggressive surgical debridement of affected tissue
- Endoscopic sinus surgery can be beneficial for chronic refractory sinusitis by improving sinus ventilation and drainage
- Surgery also important in management of intraorbital and intracranial complications of sinusitis
- For revision procedures or extensive sinus disease, surgical navigation systems that aid in anatomical localization during surgery are recommended.
|Good first-line agent for acute, uncomplicated sinusitis. Resistance a concern: S. pneumoniae 20%, H. influenzae 30-60%, and M. catarrhalis >90%. "Intermediate level" PCN-resistant pneumococcus may respond to double-dose amoxicillin.
Amoxicillin + Clavulanate
||Improved activity over common pathogens, including anaerobes and S. aureus. Drug of choice for severe acute sinusitis, acute treatment failure, and chronic sinusitis. Expensive and high rates of diarrhea.
||Reasonable drug for acute, uncomplicated sinusitis. Once daily dosing and short course appeals to patients.
||This drug, along with other 2nd generation cephalosporins such as cefpodoxime and cefdinir, provide good coverage against most S. pneumoniae and virtually all H. influenzae and M. catarrhalis.
||Clinical trials show comparable results to other drugs. Good for PCN-allergic pts. Often poorly tolerated due to taste.
||Good alternative drug for chronic sinusitis. Covers anaerobes.
||"Respiratory quinolone." Good activity against all common pathogens, multi-drug resistant pneumococcus and "atypical" pathogens (Mycoplasma, Legionella). Well tolerated and once-daily dosing. Frequently abused as a first-line agent. Should be reserved for difficult to treat infections due to unique coverage and efficacy.
|Telithromycin ||No longer FDA approved for acute bacterial sinusitis, due to hepatotoxicity concerns. Covers only main respiratory pathogens (including multi-drug resistant pneumococcus), avoiding collateral damage to gram negatives and anaerobes. Reasonable option for PCN-allergic patients.
- Frequent follow-up necessary until complete resolution of disease
- If Sx not resolving, consider repeat Cx (bacterial, fungal, and AFB), CT imaging, and reconsider DDx
- Neoplasms such as sinonasal lymphoma and KS should remain in DDx
- Clinical outcome reflects stage of HIV: Acute sinusitis likely to resolve with CD4 >200, chronic sinusitis common with CD4 <200, and risk of life-threatening infections increases with CD4 <50
- Otolaryngology consultation recommended for recurrent/chronic sinusitis or refractory acute infection not responsive to initial medical therapy. Refer if suspect complication of sinusitis (spread of infection) or if suspicious for malignancy.
- Nasal endoscopy and endoscopy-guided sinus Cx often useful to tailor therapy in difficult cases.