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Acute Rhinosinusitis

Jake Anderson, DO
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11:48
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Acute rhinosinusitis is one of the most common conditions we see in primary care. In this segment, Dr. Jacob Anderson gives us a helpful primer on the presentation, diagnosis, and treatment of acute rhinosinusitis, whether viral or bacterial in origin.

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Chris -

I appreciated this review of this common condition but I disagree with the antibiotic recommendation that doxycycline be third line while fluoroquinolones are second line for acute bacterial sinusitis.

I don't know whether there was a specific reference for this recommendation, but in looking at the reference in the list for this piece, the most recent is the 2016 AFP paper "Current Concepts in Adult Acute Rhinosinusitis." Their antibiotics recommendations include both fluoroquinolones and doxycycline as second line options.

The Canadian "Orange Book" (Anti-infective Guidelines for Community-acquired Infections, 2013 Edition) has doxycycline as one of the second line options and has fluoroquinolones as third line.

UpToDate similarly has fluoroquinolones as third line, noting that "fluoroquinolones should be reserved for those who have no alternative treatment options as the serious adverse effects associated with fluoroquinolones generally outweigh the benefits for patients with acute sinusitis."

So even though the fluoroquinolones are likely slightly more efficacious than doxycycline for this, when considering possible side effects and antibiotic stewardship would it not be most reasonable to consider doxycycline at least an equal second-line option to the fluoroquinolone rather than characterizing it as a third line option as this segment has done?

Neda F., MD -

Chris, you are so astute, as always! Jake wrote the following: "after re-reviewing the guidelines from the IDSA and the AAO-HNS, the writer is correct in that doxy and a respiratory FQ should be be considered 2nd line if high dose amox-clav is not an option. I shouldn’t have presented it as plan B and plan C, but rather either as plan B." We're correcting the written summary and the audio to reflect this. Thanks so much for your eagle eyes (and ears).

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A World of (Bladder) Hurt Full episode audio for MD edition 186:36 min - 88 MB - M4AHippo Primary Care RAP - March 2019 Written Summary 1 MB - PDF

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