What is the recommended treatment for bacterial rhinosinusitis?

Treatment of Bacterial Rhinosinusitis

Amoxicillin-clavulanate is recommended as the first-line empiric antimicrobial therapy for acute bacterial rhinosinusitis (ABRS) in both adults and children, with treatment duration of 5-7 days for adults and 10-14 days for children. 1

Diagnosis Before Treatment

• ABRS should be diagnosed based on clinical criteria before initiating antibiotics, with key indicators being: symptoms lasting >7 days, purulent nasal discharge, maxillary tooth/facial pain (especially unilateral), unilateral sinus tenderness, and worsening symptoms after initial improvement 1
• Imaging is not recommended for uncomplicated ABRS due to high prevalence of abnormal findings in viral rhinosinusitis 1

First-Line Treatment

• For adults with uncomplicated ABRS, watchful waiting (without antibiotics) is an appropriate initial strategy for mild symptoms, with assurance of follow-up 1
• When antibiotics are indicated:
  • Amoxicillin-clavulanate is preferred over amoxicillin alone for both adults (weak recommendation) and children (strong recommendation) 1
  • Standard dose amoxicillin-clavulanate for mild disease with no risk factors for resistant pathogens 1
  • High-dose amoxicillin-clavulanate (2g orally twice daily for adults or 90 mg/kg/day orally twice daily for children) for areas with high prevalence of penicillin-resistant S. pneumoniae, moderate disease, or patients with risk factors for resistant pathogens 1

Treatment Duration

• Adults: 5-7 days for uncomplicated ABRS (weak recommendation) 1
• Children: 10-14 days is recommended (weak recommendation) 1

Alternative Antibiotics for Penicillin Allergy

• For non-Type I hypersensitivity reactions (e.g., rash):
  • Cephalosporins (cefpodoxime proxetil, cefuroxime axetil, or cefdinir) 1, 2
• For Type I hypersensitivity reactions (anaphylaxis):
  • Respiratory fluoroquinolones (levofloxacin, moxifloxacin) for adults 1, 3, 4
  • Trimethoprim/sulfamethoxazole (TMP/SMX), doxycycline, or macrolides, though these have limited effectiveness with potential bacterial failure rates of 20-25% 1

Treatment Failure

• If symptoms worsen after 48-72 hours or fail to improve after 3-5 days of initial therapy, an alternative management strategy is recommended 1
• For patients initially managed with observation, begin antibiotic therapy 1
• For patients initially treated with antibiotics, change to a different antibiotic 1
• Consider obtaining cultures by direct sinus aspiration or endoscopically guided cultures of the middle meatus if patients fail to respond to empiric therapy 1

Adjunctive Treatments

• Recommended:
  • Intranasal saline irrigation with physiologic or hypertonic saline (weak recommendation) 1
  • Intranasal corticosteroids, especially in patients with history of allergic rhinitis (weak recommendation) 1
• Not recommended:
  • Topical or oral decongestants and/or antihistamines (strong recommendation against) 1

Special Considerations

• Prior antibiotic use within 4-6 weeks is a risk factor for infection with resistant organisms 1
• Routine coverage for Staphylococcus aureus (including MRSA) during initial empiric therapy is not recommended 1
• Referral to a specialist (otolaryngologist, infectious disease specialist, or allergist) is indicated for patients who are seriously ill, immunocompromised, continue to deteriorate despite extended antibiotic therapy, or have recurrent episodes 1

Common Pitfalls

• Overuse of antibiotics for viral rhinosinusitis - remember that most cases of rhinosinusitis are viral and will resolve without antibiotics 1
• Using narrow-spectrum antibiotics like amoxicillin alone when amoxicillin-clavulanate is more effective due to increasing prevalence of beta-lactamase producing organisms 1
• Prescribing fluoroquinolones as first-line therapy when they should be reserved for patients with beta-lactam allergies or treatment failures to prevent resistance 1
• Using decongestants for more than 3 days, which can lead to rebound congestion 5