32 yo woman with sinusitis Started with runny nose, cough, and sore throat 10 days ago Developed nasal congestion and drainage 1 day later On day 6 seen by PCP, with fever and above symptoms, started on azithromycin Now seeing you with persistent left sided facial pain and fever

Exam 132/78, 92, 12, Tender to palpation in L maxillary area Otherwise normal

What would you do now? a)Sinus X ray b)Sinus CT c)Refer to ENT for sinus culture d) No further testing

What would you do now? a)Stop antibiotics b)Amoxicillin/clavulanate c)Linezolid d)Moxifloxacin

Sinusitis, bacterial more likely if: Symptoms lasting for ≥ 10 days without evidence of clinical improvement Onset with severe symptoms or fever ≥ 102 F and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days Worsening symptoms (new onset of fever, headache, or increase in nasal discharge following a URI that was initially improving

Sinusitis, evaluation Good history and exam X ray and CT – Very high rates of false positives in viral URI CT reasonable if surgery is planned or if complications occur (OM, CST) Referral to ENT reasonable in patients who are not improving on appropriate therapy or if suppurative complications occur

Sinusitis, treatment Amoxicillin-clavulanate is the preferred empiric regimen, for 5-7 days in adults (14 in children) Amoxicillin alone, macrolides, TMP/SMX, not recommended for initial empiric therapy FQ not recommended routinely due to cost and spectrum of activity In penicillin allergy doxycycline or FQ are options for empiric therapy No need to cover for MRSA routinely