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No Evidence for Distinguishing Bacterial from Viral Acute Rhinosinusitis Using Symptom Duration and Purulent Rhinorrhea: A Systematic Review of the Evidence Base Medard F. M. van den Broek, Corien Gudden, Wouter P. Kluijfhout, Manon C. Stam-Slob, Mark C. J. Aarts, Nina M. Kaper and Geert J. M. G. van der Heijden Otolaryngology -- Head and Neck Surgery published online 10 February 2014 DOI: 10.1177/0194599814522595 The online version of this article can be found at: http://oto.sagepub.com/content/early/2014/02/10/0194599814522595

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Rapid Systematic Review

No Evidence for Distinguishing Bacterial from Viral Acute Rhinosinusitis Using Symptom Duration and Purulent Rhinorrhea: A Systematic Review of the Evidence Base

Otolaryngology– Head and Neck Surgery 1–5 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814522595 http://otojournal.org

Medard F. M. van den Broek, MD1,2*, Corien Gudden, MD1,2*, Wouter P. Kluijfhout, MD1,2*, Manon C. Stam-Slob, MD1,2*, Mark C. J. Aarts, MD, PhD1, Nina M. Kaper, MD1, and Geert J. M. G. van der Heijden, PhD1,2,3

No sponsorships or competing interests have been disclosed for this article.

Abstract Objective. To evaluate the diagnostic value of symptom duration and purulent rhinorrhea in adults suspected of having acute bacterial rhinosinusitis.

Keywords acute rhinosinusitis, acute viral rhinosinusitis, acute bacterial rhinosinusitis, diagnosis, purulent rhinorrhea, nasal discharge, symptom duration, evidence-based medicine Received November 11, 2013; revised January 13, 2014; accepted January 15, 2014.

Data Sources. PubMed, EMBASE, and the Cochrane Library. Review Methods. We performed a comprehensive systematic search on March 28, 2013. We included studies on the diagnostic value of duration of symptoms and purulent rhinorrhea in patients suspected of having acute bacterial rhinosinusitis. We assessed study design of included articles for directness of evidence and risk of bias. We extracted prevalence and positive and negative predictive values. Results. Of 4173 unique publications, we included 1 study with high directness of evidence and moderate risk of bias. The prior probability of bacterial rhinosinusitis was 0.29 (95% confidence interval [CI], 0.24-0.35); we could not extract posterior probabilities. Odds ratios (95% CI) from univariate analysis were 1.03 (0.78-1.36) for duration of symptoms and 2.69 (1.39-5.18) for colored discharge on the floor of the nasal cavity. Conclusion and Recommendation. We included 1 study with moderate risk of bias, reporting data in such a manner that we could not assess the value of symptom duration and purulent rhinorrhea in adults suspected of having acute bacterial rhinosinusitis. Recommendations to distinguish between a viral and a bacterial source based on purulent rhinorrhea are not supported by evidence, and the decision to prescribe antibiotic treatment should not depend on its presence. Based on judgment driven by theory and subsidiary evidence of a greater likelihood of bacterial rhinosinusitis after 10 days, antibiotic therapy may seem a reasonable empirical option.

Clinical Scenario A 58-year-old woman visits your ear, nose, and throat (ENT) outpatient clinic with complaints of purulent rhinorrhea, nasal obstruction, loss of smell, and facial pressure for 2 weeks. On physical examination, you find right maxillary sinus tenderness and purulent rhinorrhea. You wonder whether the duration of her symptoms and the presence of purulent rhinorrhea indicate that the origin of her acute episode of rhinosinusitis is bacterial. If so, these symptoms could help you to accurately prescribe antibiotics to this patient.

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Department of Otorhinolaryngology and Head & Neck Surgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands 2 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands 3 Department of Social Dentistry, Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University, Amsterdam, the Netherlands * These authors contributed equally to this article. Corresponding Author: Nina M. Kaper, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, the Netherlands. Email: [email protected]

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Otolaryngology–Head and Neck Surgery

Background

Pubmed 2446

Acute rhinosinusitis (ARS) is defined as symptomatic inflammation of the sinuses and nasal cavity with a symptom duration of 12 weeks or less. The incidence of ARS is high, and it is estimated to occur 2 to 5 times per year in an average adult.1 The diagnosis is responsible for major direct health care costs and has a huge socioeconomic impact by decreased productivity and quality of life.2,3 Viral rhinosinusitis can promote growth of bacterial pathogens by obstructing sinus drainage. About 0.5% to 2.0% of viral infections are complicated by acute bacterial rhinosinusitis (ABRS).4 Accurate differentiation between a viral and bacterial source of ARS can help to avoid unnecessary prescription of antibiotics. The current reference test to distinguish between bacterial and viral rhinosinusitis is a culture from either sinus puncture or antral aspirate obtained by nasal endoscopy.3 However, this is an invasive diagnostic test with a waiting time for culture results, so feasibility is low in daily practice. Current clinical practice guidelines recommend that the presence of a bacterial infection is more likely with a duration of symptoms of 10 days.1,3,5,6 Purulent nasal discharge is one of the cardinal symptoms of ABRS, although alone it cannot differentiate between a viral or a bacterial pathogen.3

EMBASE 3041

Cochrane 384

4871 Exclude duplicates Exclusion (4120) -Immunocompromised patients -Aberrant anatomy of nose area/intubation -Animal or in vitro studies -Study design: casereports, meta-analyses, reviews, non-diagnostic Full text not available: 0 Cross references: 1

Screening title/abstract* 4173

Screening full text** 53 Study assessment** 6

Inclusion: -Adults suspected of acute (

No evidence for distinguishing bacterial from viral acute rhinosinusitis using symptom duration and purulent rhinorrhea: a systematic review of the evidence base.

To evaluate the diagnostic value of symptom duration and purulent rhinorrhea in adults suspected of having acute bacterial rhinosinusitis...
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