This therapeutic care plan will utilized the “I can treat and prescribe framework” to ensure that appropriate patient treatments are selected using a step by step approach, including assessment integration, drug and/or disease related problems, therapeutic goals, therapeutic alternatives and indications, plan of care and evaluation (OPHCNPP, 2012). By going through each step of this framework, and including or excluding treatment options based on individual patient factors and strong clinical evidence, this clinician will arrive at the most suitable treatment plan for the patient.
H.K (32 year old male) presented with persistent facial pain for 7 days. He reported having a headache (6/10 on a pain scale) upon bending forward and awakening, occasional tooth pain, no nasal drainage, and no cough. H.K denied fever or chills but admitted to feeling “run-down”. His past medical history included varicella zoster at age 5 years, seasonal allergic rhinitis (pollen), viral respiratory tract symptoms 2 weeks ago (now resolved), and no recent antibiotic use over the past 3 months. He is married with two children who are not in daycare (ages 8 and 9). H.K is a supermarket manager, non-smoker, and denied substance abuse. The patient reported having private prescription drug coverage but was only taking Advil cold and sinus (2 tablets orally every 6 hours as required) with good effect. H.K’s vitals were taken (temp. 37.5°C tympanic, HR 74 reg., R 12 reg. and equal). His head and neck examination revealed that his sclera were clear and his pupils were round, reactive to light with accommodation. There was tenderness to palpation of the frontal and maxillary sinuses.
Transillumination of the right and left maxillary sinuses revealed an opaque surface. His nares were erythematous and edematous with no obvious discharge. There was cobblestoning of the pharynx with slight erythema. His tonsils were two plus in size with no exudates. His neck examination revealed the absence of lymphadenopathy, the thyroid was non-palpable, and his chest examination revealed clear lung fields. The diagnosis of acute sinusitis was made based on H.K’s presenting signs and symptoms. The two most common predisposing events for acute bacterial sinusitis are acute viral upper respiratory infections and allergic inflammation (80% and 20% of bacterial infections, respectively) (Desrosiers et al., 2011). Complications of sinusitis are very rare and are estimated to occur in 1 in 1,000 cases (Hwang, 2009). In complicated sinusitis, the orbit of the eye is the most common structure involved and is usually caused by ethmoid sinusitis (Hwang, 2009).
Patients who present with visual symptoms (diplopia, decreased visual acuity, disconjugate gaze, difficulty opening the eye), severe headache, somnolence or high fever should be evaluated with emergent care suspected (H.K had none of these symptoms) (Hwang, 2009). Most adult patients diagnosed with acute sinusitis become well or nearly well after 7 to 10 days, but 25% are still symptomatic after 14 days (Worrall, 2011). H.K had no untreated medical conditions contributing to his acute sinusitis (not pollen season). A primary health care nurse practitioner can effectively diagnose, treat and manage adults who have symptoms like H.K according to the Nurse Practitioner Practice Standard of Ontario (CNO, 2011). His condition was not life threatening and did not necessitate a referral to a physician, specialist or transfer of care. H.K was taking Advil cold and sinus, a drug that was appropriately dosed (1-2 tablets orally every 6 hours as required to a maximum of 6 tablets in 24 hours), which is clinically indicated for sinus pain in adults and is not too complex (CPA, 2013).
This drug was deemed safe for him after a review of contraindications, including hypersensitivity to the agent, nonsteroidal anti-inflammatory drug-induced (NSAID) asthma or urticartia, aspirin triad, pre-operative coronary bypass surgery, coronary artery disease, monoamine oxidase inhibitor use within 14 days, uncontrolled or severe hypertension, and urinary retention (Epocrates, 2013). For H.K, the oral route of medication administration was most appropriate, the least invasive and the easiest way for an adult to take drugs (Brophy et al, 2011). Advil cold and sinus is not a cytochrome P450 system inhibitor, which is the main (or partial) cause for large differences in the pharmacokinetics of other drugs (Rx Files, 2012, Epocrates, 2013).
The patient was not taking borrowed prescriptions, using drugs from previous occurrences of the condition, or experiencing any adverse drug events/reactions to Advil cold and sinus. Also, he was not being double dosed or experiencing therapeutic duplication of drugs belonging to the same pharmaceutical class. H.K had no untreated medical conditions (other than his new acute sinusitis), was not taking drugs prescribed by other clinicians and there were no other factors (communication errors, non-adherence, financial restrictions) influencing his ability to receive medication.
Antibiotic therapy should be reserved for patients with acute bacterial sinusitis as defined by a complete history and physical examination (AMA, 2008). A “wait and see” approach has been suggested in recent Canadian guidelines as a means of differentiating bacterial sinusitis from a viral respiratory tract infection (Desrosiers et al., 2011). Initiation of treatment should take place 7 to 10 days after persistent symptoms or when signs compatible with acute sinusitis occur (Desrosiers et al., 2011). Since H.K’s facial pain had lasted for 7 days, the decision was made with the patient to treat. Goals of care were established (with the patient) including maximizing symptom relief (especially drainage of congested sinuses), eradication of infection, and prevention of re-occurrence and complications (Fryters & Blondel-Hill, 2011). Five drug choices were selected and scrutinized as potential treatment options for H.K, including first and second line therapies (appendix 1) (ARP, 2012).
The primary bacterial pathogens involved in the development of acute sinusitis for adults are Streptococcus pneumonia and Haemophilus influenzae (AMA, 2008). Canadian antimicrobial resistance data of S. pneumoniae describes that penicillin resistance rates range from 14% to16% in Central Canada (Powis et al., 2004). Amoxicillin is a first line drug therapy that remains active against S. pneumoniae with the rate of resistance under 2% (Brook et al, 2006) and also retains the best coverage of oral beta-lactam agents against S. pneumoniae (AMA, 2008). It is available in a capsule, chewable tablet or powder for oral suspension (H.K had no dysphagia and preferred to take capsules) (CPA, 2013). Amoxicillin should not be prescribed to a patient more than once in a 3-month period (H.K had not taken it in the last 3 months) (ARP, 2012). This drug is acid resistant, rapidly absorbed after oral administration, and is stable in the presence of gastric acid allowing for adequate systemic concentrations (H.K was not taking drugs that affect gastric acid production) (CPA, 2013).
Pertinent adverse affects of the drug are diarrhea, nausea, headache, vomiting, abdominal pain, anaphylaxis, anemia, AST/ALT elevation, mucocutaneous candidiasis, rash and pseudomembranous colitis (Medscape Reference, 2013). Amoxicillin is contraindicated with anaphylaxis reaction to penicillins or cephalosporins (Epocrates, 2013). Several cautions to consider when prescribing amoxicillin to H.K include him having clostridium difficile infection, infectious mononucleosis (result is skin rash), bacterial/fungal superinfections, allergy to cephalosporins, and carbapenems, (Medscape Reference, 2013). Also, serious drug interactions include bcg/typhoid vaccine live, doxycycline, minocycline, probenecid and tetracycline (Epocrates, 2013). H.K did not have any of the contraindications, cautions, or potential medication interactions relevant to taking amoxicillin, so it was deemed safe for him to take.
Amoxicillin was selected as a treatment option for H.K (appendix 1). The three times a day (500 mg) option was selected to ensure simplicity, when compared to the 875 mg twice a day option that would require H.K to take two possibility identical capsules (a 500 mg and a 250 mg), increasing the likelihood of medication error (Epocrates, 2013). A primary concern for individuals infected with H. influenzae is ampicillin resistance, mediated by the production of a beta-lactamase, which is produced by approximately 19% of the bacteria (Zhanel et al, 2003). H. influenzae remains predictably susceptible to amoxicillin-clavulanate (a second line therapy) which possesses the added benefit of stability against beta-lactamases and cephalosporins (Tristam et al, 2007).
Amoxicillin-clavulanate is also effective against most penicillin-resistant S. pneumoniae (MacGowan et al., 2004). It has enhanced gram positive activity and should be used in patients where risk of bacterial resistance is high, consequences of failure of therapy are greatest, or for patients not responding to first-line therapy (DeRosiers, et al, 2011). Common side effects of this drug are nausea, vomiting, diarrhea, rash and uticartia (Poole-Arcangelo & Peterson, 2013; Rx Files, 2013). Higher rates of diarrhea and other gastrointestinal side effects occur with amoxicillin-clavulanate than with amoxicillin alone (Burns et al., 2009). It is also considered a more costly sinusitis treatment (ARP, 2012; Rx Files, 2012). Amoxicillin-clavulanate was added as a treatment option for H.K (see appendix 1). The clinician selected the two times a day option (875 mg) because the clavulanic acid daily dose is less, resulting in a decreased likelihood of the patient experiencing adverse effects compared with a more frequent dosing schedule option such as every 8 hours (Rx Files, 2012).
As a result of activity against beta-lactamase–producing H. influenza and S. pneumonae (Zhanel & Lynch, 2009), cefprozil and cefuroxime axetil have a second line treatment role in acute sinusitis (ARP, 2012). With the expanded spectrum of activity, ability to achieve adequate concentrations in tissues, suitability for twice-daily dosing, favorable toxicity profile, and proven tolerability of cephalsporins, they are a safe alternative for treatment (Poole-Arcangelo & Peterson, 2013). However, they have a broader range of activity and are more costly than amoxicillin (Rx Files, 2012; ARP, 2012). Second line drugs cefuroxime axetil and cefprozil were added as treatment options for H.K (see appendix 1). The 250 mg dose was selected for both drugs due to ease of use (smaller pills, easier to swallow), patient related factors (H.K was not immunocompromised) and disease related factors (H.K’s sinusitis had no complications).
In beta-lactam-allergic patients, a second line therapy such as trimethoprim-sulfamethoxazole (TMP- SMX) may be substituted for penicillin (ARP, 2012). The TMP-SMX resistance reported from Canadian laboratories is approximately 14% (Desrosiers et al., 2011). Increased pnuemoncoccal and H. influenza resistance rates make TMP-SMX a less desirable agent, however it is one of the most cost-effective options for patients with financial constraints (not an issue with H.K) (ARP, 2012). The most common side effects of this drug are rash, fever and gastrointestinal symptoms (Poole-Arcangelo & Peterson, 2013; Rx Files, 2012). Drugs containing sulfa (such as TMP-SMX) potentiate the effects of warfarin, phenotoin, hypoglycemic agents and methotrexate (Poole-Arcangelo & Peterson, 2013). Since H.K is not taking these drugs, TMP-SMX was selected as a treatment option (see appendix 1). One double strength tablet was selected over two single strength tablets for simplicity of administration.
The general approach to the non-pharmacological management of acute sinusitis requires utilizing adjunctive therapies. Decongestants, intranasal corticosteroids (INCS), antihistamines, mucoltylics and analgesics are treatment options. A decongestant may be used to reduce mucosal edema and facilitate aeration and drainage (Desrosiers et al., 2011). Oral decongestants have been shown to improve nasal congestion and can be used until symptoms resolve. (Desrosiers et al., 2011). Topical decongestants are controversial and should not be used for longer than 72 hours due to the potential for rebound congestion (ARP, 2013). INCS reduce inflammation and edema of the nasal mucosa, nasal turbinates, and sinus ostia (Desrosiers et al., 2011). INCS are minimally absorbed and have a low incidence of systemic adverse effects (Desrosiers et al., 2011). Adverse effects include transient nasal irritation, epistaxis, pharyngitis, rhinitis, headache, and changes to taste, smell and voice (Rx Files, 2012).
A Cochrane review evaluating three INCS drugs for acute sinusitis found limited but positive evidence for INCS as an adjuvant to antibiotics (Zalmanovici & Yaphe, 2009). Antihistamines are often used to relieve symptoms because of their drying effect, however there are no studies to support their use in the treatment of acute sinusitis (Desrosiers et al., 2011). Guaifenesin is a mucolytic that has been used to thin mucus and improve nasal drainage, however because it has not been evaluated in clinical trials, it was not recommended as an adjunct treatment for sinusitis (Rosenfeld et al, 2007). Selection of analgesics should be based on the severity of pain. Tylenol or an NSAID given alone or in combination with an opioid is appropriate for mild to moderate pain associated with sinusitis (Rosenfeld et al, 2007).
Recent Canadian guidelines suggest that limited evidence exists supporting the beneficial effects of saline irrigation in patients with acute sinusitis (Desrosiers et al., 2011). Despite limited evidence, saline therapy, either as a spray or high-volume irrigation, has seen widespread use as adjunct therapy (Desrosiers et al., 2011). Although the utility of saline sprays remains unclear, the use of saline irrigation as ancillary therapy is based on evidence of moderate symptomatic benefit and favourable tolerability (Desrosiers et al., 2011). Some additional comfort measures for patients with symptoms of acute sinusitis include maintenance of adequate hydration and application of warm facial packs. No high quality trials have demonstrated that these comfort measures are effective (Worrall, 2011).
As viral infections predispose individuals to acute sinusitis, strategies (such as handwashing) that focus on patient education of reducing viral transmission help to reduce the incidence of bacterial sinusitis (Desrosiers et al., 2011). Educating patients about common predisposing bacterial sinusitis factors may be considered as a preventative strategy (Desrosiers et al., 2011). Prophylactic antibiotics are not effective in preventing viral episodes or the development of subsequent bacterial sinusitis, and are not recommended (Desrosiers et al., 2011). Also, there is no evidence that influenza or pneumococcus vaccinations reduce the risk of contracting acute sinusitis (Rosenfeld et al, 2007).
Recent reviews have found limited evidence for alternative and complementary medicine (Scheid & Hamm, 2004). Alternative practices that have failed to show efficacy include acupuncture, chiropractic, naturopathy, aromatherapy, massage and therapeutic touch (Desrosiers et al., 2011). Vitamin C preparations and zinc lozenges are also felt to be controversial (Scheid & Hamm, 2004). Studies of zinc lozenges for the common cold have produced mixed results (Desrosiers et al., 2011). One recent meta-analysis of echinacea preparations has shown some positive effects in reducing duration of respiratory tract symptoms (Barrett et al, 1999). However, the widespread use of echnichea in the treatment of acute sinusitis is not well supported (Desrosiers et al., 2011). A recent Cochrane review found that when antibiotics were given to patients, they increased recovery time from sinusitis symptoms (Ahovuo-Saloranta, 2008). The choice of first-line treatment is based on the anticipated clinical response of a patient, as well as the microbiologic flora likely to be present.
Also, when selecting an antibiotic regimen for H.K, the clinician considered the medication cost, medication safety profile, adverse effects, and local patterns of bacterial resistance in order to maximize therapy (Hickner et al., 2001). The recommended antibiotic regimen is specific for H.K, who did not have any intracranial/orbital complications or a compromised immune function, and has normal renal function. In the absence of drug allergies and presence of resistant organisms, amoxicillin was selected for H.K as it is a first line therapy, is generally effective against susceptible and intermediate resistant pneumococci (Brophy et al, 2011), low cost (ARP, 2012), high patient tolerability, and relatively narrow antimicrobial spectrum (Aring & Chan, 2011). Factors suggesting greater risk of penicillin resistant streptococci include antibiotic use within the past 3 months, chronic symptoms present for longer than 4 weeks, and parents of children in daycare (H.K had none of these risk factors).
When antibiotics are prescribed by the clinician, the duration of treatment should be 5 to10 days as recommended by product monographs (Desrosiers et al., 2011). For H.K, the clinician utilized product monographs and other evidence based guidelines for determining the appropriate duration of treatment (CPA, 2013; ARP, 2013). Based on the information and discussion presented in this paper, amoxicillin 500 mg three times a day for 10 days (CPA, 2013) was selected as the most appropriate treatment for H.K (see appendix 2). H.K was instructed by the clinician to take his medication until finished, not share it, and to store at room temperature away from moisture, heat and light (Epocrates, 2013). He was taught about the drug’s side effects and that overdose symptoms may include confusion, behavior changes, severe rash, decreased urination, or seizure (Epocrates, 2013).
He was provided health teachings by the clinician, including seeking emergency medical help if exhibiting any signs of an allergic reaction (hives, difficulty breathing, swelling of the face, etc.) or experiencing serious side effects (white patches/sores inside his mouth/lips, fever, swollen glands, rash, itching, joint pain, pale/yellowed skin or eyes, dark colored urine, fever, confusion/weakness, severe tingling, numbness, pain, muscle weakness, easy bruising, unusual bleeding, purple/red pinpoint spots under his skin) (Epocrates, 2013). H.K was provided health teachings regarding reducing the risk of contracting viral infections through hand washing techniques. Complementary therapies, alternative medicines, comfort measures, saline prophylactic antibiotic usage and vaccines were not recommended to H.K. He was also instructed about the role these treatments play in acute sinusitis treatment. Only evidenced-based adjunctive therapies as described in this paper have been selected for H.K, including INCS therapy (see appendix 3), analgesics (Advil cold and sinus) and oral decongestants (Advil cold and sinus).
H.K agreed to this treatment plan. Based on H.K’s history and physical exam findings, a follow-up examination would be required if no improvement is seen within 72 hours of antibiotic administration, as this could indicate treatment failure (Derosier et al, 2011). The patient was advised to return in 72 hours if there were no improvements in symptoms. He did not return to the clinic for follow-up. If H.K had deteriorated at any time, the clinician would have reassessed for acute complications, other diagnoses and adherence to treatments (Derosier et al, 2011). If H.K experienced a type 1 hypersensitivity reaction to amoxicillin at any time, other pharmacological options would have been considered. A phone call was placed one week after H.K’s medical visit to conduct a post-visit evaluation, and he reported that his symptoms were nearly resolved (pharmacological and non-pharmacological therapy evaluation).
Since H.K demonstrated signs of clinical improvement, a follow-up visit or possible referral to an otolaryngologist was not required (Fryters & Blondel-Hill, 2012). The original goals of care for H.K were met. He stated that he was able to manage his symptoms with the treatment plan, was grateful that no complications were experienced, and was more knowledgeable about the prescribed drugs and future prevention strategies. H.K was satisfied with his healthcare experience (self-report) and was able to verbalize non-pharmacological therapies and apply them to his situation. When faced with a similar patient in the future, the clinician will ensure that the “I treat and prescribe framework” is utilized, as it is a valuable tool for ensuring patient specific treatment. Professional feedback from the course instructor/preceptor will also be integrated into future treatment plans.
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