Management of

Viral and Bacterial Rhinosinusitis

Retno S Wardani
Rhinology Consultant
Otorhinolaryngology Head & Neck Surgery Department
Faculty of Medicine Universitas Indonesia
Dr. Cipto Mangunkusumo Hospital
Jakarta - Indonesia

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Curriculum Vitae Retno S. Wardani
•  Medical Doctor Gadjah Mada University 1990
•  ENT Specialist University of Indonesia 1998
•  PhD in Medical Science, University of Indonesia, 2011
•  Teaching Faculty of Rinology Division – ENT Department
FMUI – RSCM since 1998
•  Founder of Asian Pediatric ORL Group (APOG)
•  Founder of ASEAN Young Sinus Surgeon Forum (YSSF)
•  International Board Advisory Member of Asian Research
Symposium in Rhinology (ARSR)
•  Honorary Member Italiana Societa di Rinologia
•  Past Chairperson of Rhinology Study Group Indonesian ORL - HNS
2007 – 2013
•  Past President of Asian Pediatric ORL Society 2009 – 2011
•  Past President of ASEAN Rhinology Society 2005-2007
Rhinosinusitis Symptomatology
 Epidemiological Clinical Definition Clinical Definition
Definition Adult Pediatric
Nasal blockage / Nasal blockage / Nasal blockage /
obstruction / obstruction / obstruction /
congestion congestion congestion
Nasal discharge Nasal discharge Nasal discharge
± Facial pain / ± Facial pain / ± Facial pain /
pressure pressure pressure
± Reduction or loss ± Reduction or loss ± Cough
of smell of smell
•  Based on symptoms •  AND either •  AND either
•  Validations by tele- ENDOSCOPIC ENDOSCOPIC
phone / interview SIGNS SIGNS
•  No need for ENT
exam / radiology •  AND / OR CT •  AND / OR CT
•  Question for allergic CHANGES CHANGES
symptoms
Fokkens W, Lund V, Mullol J et al. Rhinology 2012,vol 50 (Suppl 23):1-198
Web: www.ep3os.org.rhinologyjournal.com
Rhinosinusitis
 Definition of Acute Rhinosinusitis
S  Sudden onset
S  2 or more symptoms
S  One of which should be either
S  Nasal Blockage/Obstruction/Congestion Or
S  Nasal Discharge (anterior/posterior nasal drip)
S  ± facial pain/pressure
S  ± reduction or loss of smell
S  For < 12 weeks
S  With symptom free intervals if the problem is recurrent
S  With validation by telephone or interview
Fokkens W, Lund V, Mullol J et al. Rhinology 2012,vol 50 (Suppl 23):1-198
Web: www.ep3os.org.rhinologyjournal.com
 Acute rhinosinusitis can be divided into:
common cold and post-viral rhinosinusitis
 Acute Rhinosinusitis

S  Common cold / acute viral rhinosinusitis

S  Duration of symptom less than 10 days

S  Acute post-viral rhinosinusitis

S  Increase of symptoms after 5 days or
S  Persistent symptoms after 10 days with
S  less than 12 weeks duration
 Acute Rhinosinusitis
S  Acute bacterial rhinosinusitis (ABRS)
S  Is suggested by the presence of at least
3 symptoms/signs of:
S  Discoloured discharge (unilateral predominance)
and purulent secretion in nasal cavity
S  Severe local pain with unilateral predominance
S  Fever (>380)
S  Elevated ESR / CRP
S  “Double sickening” (deterioration after an initial
milder phase of ilness)
Fokkens W, Lund V, Mullol J et al. Rhinology 2012,vol 50 (Suppl 23):1-198
Web: www.ep3os.org.rhinologyjournal.com
 Common Cold
(acute viral rhinosinusitis)
&
post-viral rhinosinusitis

a self limiting disease

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Prevention of Antibiotic Resistance

S  We have reached a CRUCIAL TIME:

S  Rise of antibiotic resistance
S  A steady decline in the rate of discovery of new
antibiotics

CONCEPTUALLY NOVEL THERAPEUTIC

STRATEGIES AGAINST
M I C RO B I A L I N VA D E R S
 S Targeting The Innate Immune System
à efficient mucocilliar y clearance
à to eliminate the pathogen

Nasal Rinsing = Cuci Hidung

 Glucocorticoids
Suppress
Inflammation but
Spare Innate Immune
Responses in
Airway Epithelium

Robert  P.  Schleimer    

Proc  Am  Thorac  Soc    
Vol  1.  pp  222–230,  2004   19
Antibiotic For Bacterial Infection Only
Microbiological Result Frequency

No growth 9 (20,9%)
Purulent secretion should not be used to
assess the need for antibiotic therapy
à discoloration & thickening is related to
presence of neutrophils, not bacteria.
Suprohaita, Wardani RS, Munasir Z, Supriyatno B, Syarief
DR, Clinical Symptoms & PNS Plain X-ray Compare to
Nasoendoscopy Examination As Diagnostic Criteria In
Pediatric Rhinosinusitis, 2009
Identify Viral to Postviral towards
Bacterial Acute Infection
 The Need for Appropriate
Antibiotic Prescribing
Principles required for appropriate prescribing and effective
(locally compliant) guidelines:

S  OPTIMIZE diagnosis/severity assessment

S  AB TREATMENT for bacterial infection only
S  MAXIMIZE eradication of bacterial pathogens
S  RECOGNIZE (local) resistance prevalence
S  UTILIZE pharmacodynamics &
pharmacokinetics to choose most effective AB
agents and dosage
S  INTEGRATE local resistance, efficacy and
maximize cost-effectiveness
Ball et al. J Antimicrob Chemother 2002;49:31–40.
 Microbiological Result of
Pediatric Acute Bacterial Rhinosinusitis
Microbiological Result Frequency

No growth 9 (20,9%)

Staphylococcus aureus 18 (41,86%)

Streptococcus pneumoniae 14 (32,6%)

Streptococcus pyogenes 1 (2,3%)

Pseudomonas aeruginosa 1 (2,3%)

Suprohaita, Wardani RS, Munasir Z, Supriyatno B, Syarief DR, Clinical

Symptoms & PNS Plain X-ray Compare to Nasoendoscopy Examination As
Diagnostic Criteria In Pediatric Rhinosinusitis, 2009
 Empirical Antibiotics
Acute Bacterial Rhinosinusitis
1st line
S  Amoxicillin OBSERVE 48 hours
S  Co-trimoxazol

2nd line
•  Augmented Penicillin: Amox.-Clavulanat /
Ampicillin-Sulbactam
•  2nd-3rd gen. Cephalosporin: Cefuroxim, Cefaclor,
Cefixime, Cefradine, Cefprozil, Cefotiam
•  Quinolones : Ciprofloxacin, Levofloxacin,
Moxifloxacin
•  Macrolides: Erythromycin, Azithromycin,
Clarithromycin
 Azithromycin (gol azalides)
•  A key point of differentiation between
azithromycin and other macrolides is that it
demonstrates a marked post-antibiotic effect
(PAE)4
•  Generally, antibiotics having PAE allows for
less frequent dosing than those with minimal
PAE while remaining effective

1. Murray PR. Medical Microbiology; 2. Retsema J, et al. Antimicrob Agents

Chemother 1987;31:1939–47; 3. Pfizer Egypt, Product Document, Zithromax®;
4. Lode H, et al.
J Antimicrob Chemother 1996;37(Suppl.26C):1–8
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BOTTOMLINE: Pillars of professionalism6
Arnold & Stern, 2006

Professionalism

Accountability
Excellence

Humanism

Altruism
ETHICS

AUTONOMY
COMPETENCE
28
6. Dari Samsi Jacobalis, dalam WS Standar Kompetensi Dokter – Depkes, 2004
 EP3OS Based Management of
Viral & Bacterial Rhinosinusitis

S  Best avalaible external evidence systematically

identified and incorporated in the clinical
decisions
S  Is not: tell practitioner what to do
S  Is not: a legal document

S  Irreplaceable individual clinical expertise

S  Patient preference

Thank You
retno.wardani@gmail.com

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