What is the first line treatment for bacterial rhinosinusitis?

First-Line Treatment for Bacterial Rhinosinusitis

Amoxicillin-clavulanate is the recommended first-line treatment for bacterial rhinosinusitis in adults, while high-dose amoxicillin or amoxicillin-clavulanate is recommended for children, depending on risk factors for resistant pathogens. 1

Adult Treatment Algorithm

Initial Assessment:

• Determine severity of illness (mild vs. moderate-severe)
• Check for recent antibiotic use (within past 4-6 weeks)
• Assess for risk factors for resistant pathogens

First-Line Treatment Options:

For Adults with Mild Disease and No Recent Antibiotic Use:

• Amoxicillin-clavulanate (1.75-4g/250mg per day) 1
• Alternative: Amoxicillin (1.5-4g/day) 1

For Adults with Moderate Disease or Recent Antibiotic Use:

• High-dose amoxicillin-clavulanate (4g/250mg per day) 1
• Alternative: Respiratory fluoroquinolone (gatifloxacin, levofloxacin, moxifloxacin) 1, 2

For Penicillin-Allergic Patients:

• Non-Type I hypersensitivity (e.g., rash): Cefpodoxime proxetil, cefuroxime axetil, or cefdinir 1
• Type I hypersensitivity (anaphylaxis): Respiratory fluoroquinolone or doxycycline 1

Pediatric Treatment Algorithm

For Children with Mild Disease and No Recent Antibiotic Use:

• Amoxicillin (45mg/kg/day in 2 divided doses) 1
• In areas with high prevalence of resistant S. pneumoniae: High-dose amoxicillin (90mg/kg/day) 1

For Children with Moderate Disease or Recent Antibiotic Use:

• High-dose amoxicillin-clavulanate (90mg/6.4mg per kg per day) 1

For Penicillin-Allergic Children:

• Non-Type I hypersensitivity: Cefdinir, cefpodoxime proxetil, or cefuroxime axetil 1
• Type I hypersensitivity: TMP/SMX, azithromycin, clarithromycin, or erythromycin 1

Duration of Therapy

• Adults: 5-10 days depending on severity 1
• Children: 10-14 days or 7 days beyond substantial symptom improvement 1, 3

Treatment Failure Considerations

• Reassess if no improvement after 72 hours of initial therapy 1
• Consider switching to alternate antibiotic if no improvement 1
• For adults with treatment failure: Switch to respiratory fluoroquinolone, high-dose amoxicillin-clavulanate, or ceftriaxone 1
• For children with treatment failure: Consider high-dose amoxicillin-clavulanate or ceftriaxone 1

Important Clinical Pearls

1. Watchful waiting may be appropriate for uncomplicated cases with mild symptoms, as many cases resolve without antibiotics 1

2. Microbiology considerations: The major pathogens in bacterial rhinosinusitis are Streptococcus pneumoniae (30%), Haemophilus influenzae (30%), and Moraxella catarrhalis (10%) 1, 4

3. Resistance concerns: Consider local resistance patterns when selecting therapy. Risk factors for resistant pathogens include:

   • Recent antibiotic use (within 4-6 weeks)
   • Day care attendance (children)
   • Age <2 years (children)
   • High local prevalence of resistant S. pneumoniae 1

4. Common pitfalls to avoid:

   • Using macrolides as first-line therapy (high resistance rates)
   • Treating viral rhinosinusitis with antibiotics
   • Failing to reassess after 72 hours if symptoms persist or worsen
   • Using suboptimal dosing in areas with high resistance 1

5. Adjunctive therapies for symptomatic relief include:

   • Analgesics
   • Topical intranasal steroids
   • Nasal saline irrigation 1

The evidence strongly supports amoxicillin-clavulanate as first-line therapy for bacterial rhinosinusitis in adults, with consideration for high-dose regimens in patients with risk factors for resistant pathogens. For children, high-dose amoxicillin or amoxicillin-clavulanate is recommended depending on risk factors 1.