What is the recommended treatment for acute rhinosinusitis (Acute Rhinosinusitis Clinical Practice Guideline)?

Acute Rhinosinusitis Treatment Guidelines

For acute rhinosinusitis, clinicians should initially offer watchful waiting (without antibiotics) or prescribe antibiotics based on symptom severity, with symptomatic treatment including analgesics, topical intranasal steroids, and/or nasal saline irrigation as first-line management. 1

Diagnosis and Classification

• Acute rhinosinusitis is classified as either viral rhinosinusitis (VRS) or acute bacterial rhinosinusitis (ABRS) 1
• ABRS should be diagnosed when symptoms persist ≥10 days without improvement, symptoms are severe (high fever, purulent discharge, facial pain), or there is a "double-worsening" pattern (initial improvement followed by deterioration) 2
• Radiographic imaging should not be obtained for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis 1

Initial Management Approach

Watchful Waiting vs. Antibiotics

• Both watchful waiting and antibiotic therapy are proven management strategies for ABRS 1
• Watchful waiting involves delaying antibiotics for up to 7 days after diagnosis to see if symptoms resolve spontaneously 1
• Watchful waiting should only be offered when follow-up can be assured, with antibiotics started if symptoms fail to improve within 7 days or worsen at any time 1
• Most patients with ABRS improve naturally, with antibiotics providing only modest additional benefit (10-15 patients must use antibiotics for 1 additional person to benefit) 1

Symptomatic Relief

• For both VRS and ABRS, symptomatic relief options include: 1

  • Analgesics/antipyretics (acetaminophen or ibuprofen) for pain and fever
  • Saline nasal irrigation to relieve symptoms and remove mucus
  • Topical intranasal steroids (modest benefit after 15 days of use)
  • Decongestants (oral or topical)

• Important limitations for symptomatic treatments: 1

  • Topical decongestants should not be used for more than 3-5 days to avoid rebound congestion
  • Antihistamines and oral steroids should not be used routinely as they have side effects and do not reliably relieve symptoms

Antibiotic Selection

• If antibiotics are prescribed, amoxicillin with or without clavulanate is the first-line therapy for 5-10 days for most adults 1

• Standard adult dosing for amoxicillin-clavulanate: 3

  • 500 mg/125 mg every 12 hours or 250 mg/125 mg every 8 hours
  • For more severe infections: 875 mg/125 mg every 12 hours or 500 mg/125 mg every 8 hours

• For patients with penicillin allergies, alternatives include: 4, 5

  • Doxycycline
  • Trimethoprim-sulfamethoxazole (with higher bacteriologic failure rates of 20-25%)

Special Considerations

• Antibiotics have potential side effects including rash, upset stomach, nausea, vomiting, allergic reactions, and contribute to antibiotic resistance 1
• Patients should be reassessed after 72 hours of treatment; lack of improvement warrants reevaluation or change in therapy 4
• Shorter antibiotic courses (5-7 days) may be as effective as traditional 10-day courses with fewer side effects 1

Common Pitfalls to Avoid

• Prescribing antibiotics for viral rhinosinusitis, which is ineffective and contributes to antibiotic resistance 6, 2
• Using radiographic imaging for uncomplicated cases 1, 2
• Continuing nasal decongestant sprays beyond 3-5 days, which can lead to rebound congestion 1, 2
• Underutilizing simple measures like saline irrigation and adequate hydration 6
• Using broad-spectrum antibiotics when narrow-spectrum options would be sufficient 4