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32 yo woman with sinusitis

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.

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32 yo woman with sinusitis

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  1. 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

  2. Exam 132/78, 92, 12, 100.8 • Tender to palpation in L maxillary area • Otherwise normal

  3. What would you do now? • Sinus X ray • Sinus CT • Referto ENT forsinus culture d) No furthertesting

  4. What would you do now? • Stop antibiotics • Amoxicillin/clavulanate • Linezolid • Moxifloxacin

  5. 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

  6. 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

  7. 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

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