2012美国急性细菌性鼻窦炎指南

Executive Summary: IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults中文摘要：针对初级医疗医师，美国感染病学会（IDSA）将于4月15日在《临床感染性疾 病》 （Clin Infect Dis）杂志上发布其首个急性细菌性鼻窦炎指南 指南推荐，对于细菌性鼻窦感染，应使用阿莫西林-克拉维酸治疗，而非现行的标准治疗药 物阿莫西林，其原因在于加用克拉维酸有助于预防抗生素耐药；同样，为预防抗生素耐药， 指南亦不推荐使用阿奇霉素、克拉霉素、复方新诺明等常用抗生素 此外，在该指南中的其他推荐意见还包括： •若出现以下情况，则提示鼻窦感染为细菌性，须迅速给予抗生素治疗： ① 症状持续≥10天且无改善（既往其他学会所制定的指南建议等待7天） ； ② 症状严重（包括发热≥38.9℃、流涕及面部疼痛持续3~4天） ； ③ 在病毒性上呼吸道感染持续5~6天并似乎开始有所改善后，又出现新的发热、头痛或流 涕加重等症状加重的表现 •细菌性鼻窦炎仅需5~7天抗生素治疗足矣，但儿童仍需10天~2周。

•避免使用减充血药和抗组胺药，但鼻用类固醇有助减轻鼻窦感染和有过敏史患者的症状 •生理盐水冲洗鼻腔有助于缓解症状，但儿童常难以耐受鼻腔冲洗 此外，该指南还指出， 大多数鼻窦感染是由病毒引起，不需要抗生素治疗Next SectionAbstractEvidence-based guidelines for the diagnosis and initial management of suspected acute bacterial rhinosinusitis in adults and children were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America comprising clinicians and investigators representing internal medicine, pediatrics, emergency medicine, otolaryngology, public health, epidemiology, and adult and pediatric infectious disease specialties. Recommendations for diagnosis, laboratory investigation, and empiric antimicrobial and adjunctive therapy were developed.Previous SectionNext SectionEXECUTIVE SUMMARYThis guideline addresses several issues in the management of acute bacterial rhinosinusitis (ABRS), including (1) inability of existing clinical criteria to accurately differentiate bacterial from viral acute rhinosinusitis, leading to excessive and inappropriate antimicrobial therapy; (2) gaps in knowledge and quality evidence regarding empiric antimicrobial therapy for ABRS due to imprecise patient selection criteria; (3) changing prevalence and antimicrobial susceptibility profiles of bacterial isolates associated with ABRS; and (4) impact of the use of conjugated vaccines for Streptococcus pneumoniae on the emergence of nonvaccine serotypes associated with ABRS. An algorithm for subsequent management based on risk assessment for antimicrobial resistance and evolution of clinical responses is offered (Figure 1). This guideline is intended for use by all primary care physicians involved in direct patient care, with particular applicability to patients managed in community or emergency department settings. Continued monitoring of the epidemiology and rigorous investigation of the efficacy and cost-benefit of empiric antimicrobial therapy for suspected ABRS are urgently needed in both children and adults.View larger version:In this pageIn a new windowDownload as PowerPoint SlideFigure 1.Algorithm for the management of acute bacterial rhinosinusitis. Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging.Summarized below are the recommendations made in the new guideline for ABRS in children and adults. The panel followed a process used in the development of other Infectious Diseases Society of America (IDSA) guidelines that includes a systematic weighting of the strength of recommendation (eg, “high, moderate, low, very low”) and quality of evidence (eg, “strong, weak”) using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system [1–6] (Table 1). A detailed description of the methods, background, and evidence summaries that support each of the recommendations can be found in the full text of this guideline.View this table:In this windowIn a new windowTable 1.Strength of Recommendations and Quality of the EvidenceaPrevious SectionNext SectionRECOMMENDATIONSINITIAL TREATMENTI. Which Clinical Presentations Best Identify Patients With Acute Bacterial Versus Viral Rhinosinusitis?Recommendations1. The following clinical presentations (any of 3) are recommended for identifying patients with acute bacterial vs viral rhinosinusitis:i. Onset with persistent symptoms or signs compatible with acute rhinosinusitis, lasting for ≥10 days without any evidence of clinical improvement (strong, low-moderate);ii. Onset with severe symptoms or signs of high fever (≥39°C [102°F]) and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness (strong, low-moderate); oriii. Onset with worsening symptoms or signs characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection (URI) that lasted 5–6 days and were initially improving (“double-sickening”) (strong, low-moderate).II. When Should Empiric Antimicrobial Therapy Be Initiated in Patients With Signs and Symptoms Suggestive of ABRS?Recommendation2. It is recommended that empiric antimicrobial therapy be initiated as soon as the clinical diagnosis of ABRS is established as defined in recommendation 1 (strong, moderate).III. Should Amoxicillin Versus Amoxicillin-Clavulanate Be Used for Initial Empiric Antimicrobial Therapy of ABRS in Children?Recommendation3. Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in children (strong。