New infectious disease guidelines on sinusitis, STDs

Infectious Diseases Focus

In 2015, select guidelines and evidence-based reviews were released that focused on infectious disease topics such as sexually transmitted diseases (STDs), adult sinusitis, and chronic sinusitis. These publications included a multitude of pharmacotherapy recommendations and counseling pearls that are applicable to pharmacists. An overview of these topics is presented in this article. 


STD prevention and management guidance 


CDC has estimated that nearly 20 million new sexually transmitted infections occur in the United States annually, one-half of which are among those aged 15–24 years. To help prevent and treat STDs, CDC released updated guidelines in October 2015 that include new and revised screening and treatment recommendations. A few of the key changes are highlighted here; however, clinicians are encouraged to access the full set of guidelines at www.cdc.gov/std/tg2015. CDC’s changes in-clude the following:


  • Genital warts: Recommended patient-applied treatments include imiquimod, podofilox, or sinacatechins, and provider-administered treatments include cryotherapy, surgical removal, or a solution of trichloroacetic acid or bichloroacetic acid.

  • Gonorrhea: Ceftriaxone 250 mg intramuscularly and azithromycin 1 g orally, both given as a single dose, are recommended. CDC noted that single doses of oral gemifloxacin 320 mg plus azithromycin 2 g or single doses of gentamicin 240 mg intramuscularly plus azithromycin 2 g may be considered in patients allergic to cephalosporins.

  • Hepatitis C virus (HCV): All patients with HIV should be screened for HCV at initial evaluation, and CDC recommends that HCV screening with HCV antibody assays be considered at least yearly for those at high risk. 

  • Human papillomavirus (HPV): The bivalent, quadrivalent, or 9-valent HPV vaccine is recommended for females through age 26 years, whereas the quadrivalent or 9-valent HPV vaccine is recommended for males through 21 years. Vaccination is also recommended for men aged 22–26 years who have sex with men if they have not previously received the vaccine. 

  • Trichomoniasis: Testing is recommended for all women with vaginal discharge, and screening may be considered in high-prevalence settings such as STD clinics and correctional facilities, with at least annual screening for sexually active women with HIV. 

  • Retesting: Follow-up retesting for repeat infection should occur 3 months after treatment in all patients with chlamydia or gonorrhea and in female patients with trichomoniasis.


In addition to the above recommendations, CDC noted that STD prevalence is highest among adolescents and young adults, and that the presence of an STD increases the risk for acquiring and transmitting HIV and can lead to reproductive health complications. Therefore, strategies aimed at preventing STDs should be implemented, especially in higher-risk patient populations. 


CDC recommended that all patients be educated on primary STD prevention measures, such as pre-exposure vaccination (e.g., HPV, hepatitis A and B series); awareness of HIV infection, testing, transmission, and disease implications; and other risk-reduction behaviors for those who are already sexually active, such as consistent and correct use of condoms and having a limited number of sex partners. 


Inform patients that CDC has released new guidelines on the prevention and management of STDs. Educate patients on prevention tips, such as correct and consistent use of barrier protection (e.g., condoms), pre-exposure vaccination (if appropriate), and postexposure prophylaxis (if needed). Inform patients that the most reliable way to avoid STDs is to abstain from sex or to be in a long-term, mutually monogamous relationship with an uninfected partner.


Adult sinusitis: Option 
to delay antibiotics 


In April 2015, the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO–HNSF) released updated guidelines for the diagnosis and management of adult sinusitis, which include an extension of watchful waiting as a management option for most patients with uncomplicated acute bacterial rhinosinusitis, not just those with mild disease.1

Sinusitis is extremely prevalent, affecting approximately 30 million adults annually in the United States. Appropriate management of sinusitis often requires a combination of prescription and self-care strategies. AAO–HNSF’s updated guidelines, which replace the previous version published in 2007, include 12 key statements that focus on diagnostic recommendations and management strategies for viral rhinosinusitis, acute bacterial rhinosinusitis (lasting less than 4 weeks), and chronic rhinosinusitis (lasting more than 12 weeks). 


The guidelines recommend that clinicians differentiate between the various forms of sinusitis, with acute bacterial sinusitis diagnosed in those patients with persistent symptoms for at least 10 days beyond the onset of upper respiratory symptoms or in those whose symptoms worsen within 10 days after an initial improvement.


Agents such as analgesics, topical intranasal steroids, and/or nasal saline irrigation are recommended for symptomatic relief of both viral and acute bacterial rhinosinusitis. For acute bacterial sinusitis, the guidelines note that antibiotic therapy can be delayed in most patients and subsequently initiated in those whose symptoms fail to improve after 7 days or whose symptoms get worse at any point. The guidelines further note that the decision to either delay antibiotic therapy (i.e., watchful waiting) or initiate treatment immediately should be based on a shared decision-making process with the patient. When assessing the suitability of delaying treatment, clinicians are encouraged to consider the patient’s age, general health, cardiopulmonary status, and comorbid conditions. If the decision to delay antibiotic therapy is made, clinicians should be confident that patients will follow up for symptom assessment. 


If antibiotic therapy is initiated, 5 to 10 days of amoxicillin with or without clavulanate is recommended as the first-line treatment choice for most patients. An alternative antibiotic should be selected for patients who do not respond to this initial therapy. Saline nasal irrigation, topical intranasal corticosteroids, or both are recommended for symptomatic relief of chronic rhinosinusitis. The guidelines recommend against the use of topical or systemic antifungals for chronic disease.


Educate patients about the different types of sinusitis (e.g., viral vs. bacterial) and recommended treatment options. Inform patients that new sinusitis guidelines include an option to delay antibiotic treatment for the management of acute bacterial sinusitis because some patients are able to fight the infection on their own without antibiotic treatment.


Chronic sinusitis: Which treatments work best?


Results of a large systematic review published in 2015 support the treatment of adult chronic sinusitis with daily topical corticosteroids and adjunctive daily saline irrigations.2 Additional therapies are preferred for those with nasal polyps (i.e., short course of systemic corticosteroids, 3-week course of doxycycline, or a leukotriene antagonist) and those without polyps (i.e., prolonged course of antibiotics).


Chronic sinusitis is an inflammatory condition of the sinuses that lasts longer than 3 months, affecting approximately 3% to 7% of the population. Its etiology is multifactorial, and patients often present with symptoms of nasal congestion and discharge, facial pressure, and a reduced sense of smell. Because these daily symptoms can have a significant impact on patients’ quality of life, effective treatments are needed.


The research authors conducted a systematic review of 29 studies (12 meta-analyses, 13 systematic reviews, and four randomized controlled trials not previously captured by the meta-analyses) to determine the most effective medical treatments for adults with chronic sinusitis. The authors rated the therapies using the American Heart Association Grade of Evidence and Recommendation Grading Scale, with an A-I grade indicating the best supporting evidence and some grades indicating that a therapy is not effective and may actually be harmful (i.e., A-III, B-III, and C-III).


For maintenance medications, the authors gave the use of topical corticosteroid therapy and nasal saline irrigations (as adjunctive therapy to intranasal corticosteroids) both A-I grades for patients with chronic sinusitis with and without nasal polyps. The evidence showed that both therapies improved symptoms, with topical corticosteroids having additional benefits on polyp size and recurrence of polyps after sinus surgery. High-volume saline (>100 mL) techniques were shown to be better than low-volume ones, but isotonic and hypertonic saline had similar outcomes. Data on montelukast 10 mg/d supported use of this therapy for patients with nasal polyps (A-II grade); however, the authors noted that no additional benefits were observed when adding montelukast to existing topical corticosteroid therapy.


For intermittent or rescue medications, the evidence supported the use of a short course (i.e., 1 to 3 weeks) of oral corticosteroids (A-I grade) for symptomatic nasal polyposis; a limited course of doxycycline (i.e., 200 mg once, then 100 mg/d for 20 d) for nasal polyposis (B-I grade); and long-term use of macrolide therapy (i.e., >12 weeks) for patients without nasal polyps (A-II grade). Other therapies were also included in the review, such as allergy immunotherapy for maintenance therapy (C-II grade); short-term use of an anti-immunoglobulin E (anti-IgE) monoclonal antibody for those with nasal polyps and asthma (A-II grade); an anti-interleukin-5 monoclonal antibody for those with nasal polyps (A-II grade); and topical antibiotics and topical antifungals for those without polyps (A-III grade).


Explain to patients what chronic sinusitis is, what causes the condition, and the most common symptoms. Inform them that data from a new review support the use of daily intranasal corticosteroids and saline rinses for management of chronic sinusitis. Other intermittent therapies, depending upon the presence of nasal polyps, may be added when needed for persistent symptoms or an acute exacerbation.


References


  1. Otolaryngol Head Neck Surg. 2015;152:598–609

  2. JAMA. 2015;314:926–39