What is the next step in managing a 67-year-old female's persistent sinusitis, with no improvement on cefdinir (Cefdinir), and a history of idiopathic neutropenia, presenting with nasal bleeding, internal swelling, and ear discomfort?

From the Guidelines

The patient should be referred to an otolaryngologist (ENT specialist) for evaluation and possible sinus imaging to rule out complications such as fungal sinusitis, given her idiopathic neutropenia and failure to respond to cefdinir. The patient's symptoms of nasal bleeding, internal swelling, and ear discomfort are concerning and warrant direct visualization by a specialist 1. While awaiting the ENT appointment, the patient should continue saline nasal rinses to help reduce nasal congestion and add a nasal steroid spray such as fluticasone (Flonase) 1-2 sprays in each nostril daily to reduce inflammation 1.

The use of antibiotics in this patient is complicated by her idiopathic neutropenia, which may increase her risk of developing resistant or atypical infections 1. The patient's failure to respond to cefdinir, a third-generation cephalosporin, suggests that she may require alternative antibiotic therapy or culture-directed therapy, which can be obtained through endoscopic evaluation and possibly sinus aspiration by the ENT specialist 1.

Regarding ear discomfort, the patient should avoid using hydrogen peroxide and Q-tips for ear cleaning, as this can cause trauma to the ear canal and potentially push debris further into the ear 1. Instead, she can use over-the-counter ear drops like Debrox if needed, but the ear symptoms may be related to her sinus condition and should be evaluated by the ENT specialist.

Key considerations in managing this patient's care include:

• Referral to an ENT specialist for evaluation and possible sinus imaging
• Continued use of saline nasal rinses and addition of a nasal steroid spray
• Avoidance of hydrogen peroxide and Q-tips for ear cleaning
• Possible need for alternative antibiotic therapy or culture-directed therapy
• Evaluation of ear symptoms by the ENT specialist to determine if they are related to the sinus condition.

From the FDA Drug Label

To evaluate the safety and efficacy of a high dose short course of levofloxacin, 780 outpatient adults with clinically and radiologically determined acute bacterial sinusitis were evaluated in a double-blind, randomized, prospective, multicenter study comparing levofloxacin 750 mg by mouth once daily for five days to levofloxacin 500 mg by mouth once daily for 10 days Clinical success rates (defined as complete or partial resolution of the pre-treatment signs and symptoms of ABS to such an extent that no further antibiotic treatment was deemed necessary) in the microbiologically evaluable population were 91.4% (139/152) in the levofloxacin 750 mg group and 88.6% (132/149) in the levofloxacin 500 mg group at the test-of-cure (TOC) visit (95% CI [-4. 2,10] for levofloxacin 750 mg minus levofloxacin 500 mg).

The next step in managing a 67-year-old female's persistent sinusitis, with no improvement on cefdinir, and a history of idiopathic neutropenia, presenting with nasal bleeding, internal swelling, and ear discomfort, could be to consider levofloxacin as an alternative treatment option.

• Key considerations:
  • The patient's history of idiopathic neutropenia may increase the risk of infection, and levofloxacin has been shown to be effective in treating acute bacterial sinusitis.
  • The patient's symptoms, such as nasal bleeding and internal swelling, may require further evaluation and management.
  • The patient's lack of response to cefdinir may indicate a need for a different antibiotic, such as levofloxacin. 2

From the Research

Next Steps in Managing Persistent Sinusitis

The patient's condition, with no improvement on cefdinir and a history of idiopathic neutropenia, presenting with nasal bleeding, internal swelling, and ear discomfort, requires careful consideration of the next steps in management.

• The use of nasal sprays, including steroidal, saline, decongestant, antihistamine, and anticholinergic preparations, may be beneficial in managing sinonasal disease, as discussed in 3.
• Saline irrigation has been shown to improve patient-reported disease severity in patients with allergic rhinitis, with no reported adverse effects, as seen in 4.
• Topical therapies, including daily high-volume sinonasal saline irrigation and standard metered-dose topical nasal steroid therapy, are supported by evidence for refractory chronic rhinosinusitis, as stated in 5.
• The comparison of intranasal steroid application using nasal saline irrigation and a mucosal atomization device has shown that both methods are effective and safe, but with different adverse experiences, as reported in 6.
• The use of antibiotics may be indicated in persistent cases of rhinosinusitis if symptoms persist beyond a period of observation, as outlined in 7.

Considerations for Idiopathic Neutropenia

The patient's history of idiopathic neutropenia should be taken into account when considering the next steps in management, as it may affect the patient's response to treatment and increase the risk of adverse effects.

• The use of antibiotics and other medications should be carefully considered, as patients with idiopathic neutropenia may be more susceptible to adverse effects and drug interactions.
• The patient's condition should be closely monitored, and adjustments to treatment should be made as necessary to ensure the best possible outcome.

Symptom Management

The patient's symptoms, including nasal bleeding, internal swelling, and ear discomfort, should be addressed through the use of topical therapies and other management strategies.

• Saline irrigation and nasal sprays may help to alleviate symptoms and improve patient-reported disease severity, as discussed in 3 and 4.
• The use of mucosal atomization devices and other topical therapies may also be beneficial in managing symptoms and improving quality of life, as reported in 6.