From the Guidelines
Acute bacterial rhinosinusitis is best treated with amoxicillin-clavulanate as first-line therapy for 5 to 10 days for most adults. The choice of antibiotic should be based on the severity of symptoms and the likelihood of bacterial infection. According to the clinical practice guideline update for adult sinusitis 1, amoxicillin with or without clavulanate is recommended as first-line therapy. For patients with penicillin allergy, alternative options such as doxycycline or a respiratory fluoroquinolone may be used 1.
Diagnosis and Treatment
Diagnosis of acute bacterial rhinosinusitis should be based on symptoms lasting more than 10 days without improvement, severe symptoms with purulent discharge and facial pain for 3-4 days, or worsening symptoms after initial improvement. Supportive measures include:
- Saline nasal irrigation
- Intranasal corticosteroids like fluticasone 1-2 sprays per nostril daily
- Analgesics for pain relief Decongestants may provide temporary symptom relief but should not be used for more than 3 days to avoid rebound congestion.
Indications for Antibiotics
Antibiotics are indicated when bacterial infection is suspected, as most cases of rhinosinusitis are viral and self-limiting. Bacterial infection typically develops as a secondary complication when the sinus drainage pathways become obstructed, allowing bacteria like Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis to proliferate. Patients should seek medical attention if symptoms worsen despite treatment, if they develop high fever, severe headache, visual changes, or mental status changes, as these may indicate complications requiring urgent intervention 1.
High-Value Care Advice
Most patients with acute rhinosinusitis should be managed with supportive care, and antibiotic treatment should be reserved for patients with persistent symptoms or severe disease 1. Clinicians should prioritize the use of amoxicillin-clavulanate as first-line therapy and consider alternative options for patients with penicillin allergy or other contraindications.
From the FDA Drug Label
- 4 Acute Bacterial Sinusitis: 5 Day and 10 to 14 Day Treatment Regimens Levofloxacin tablets are indicated for the treatment of acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis [see Clinical Studies (14.4)].
Levofloxacin is indicated for the treatment of acute bacterial rhinosinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.
- The treatment regimens are 5 days and 10 to 14 days. 2
From the Research
Definition and Diagnosis of Acute Bacterial Rhinosinusitis
- Acute bacterial rhinosinusitis (ABRS) is a common and uncomfortable condition, frequently caused by Streptococcus pneumoniae or Haemophilus influenzae 3.
- The cardinal features of ABRS are unilateral facial pain or pressure, fever greater than 102°F (39°C), and purulent nasal discharge with obstruction of the nasal passages 4.
- Diagnostic testing for ABRS with antral puncture is impractical due to its invasiveness, and point-of-care testing for elevated C-reactive protein may be helpful but is not widely available 4.
Treatment of Acute Bacterial Rhinosinusitis
- Antibiotic therapy should be considered in patients with prolonged or more severe symptoms, and narrow-spectrum antibiotics such as amoxicillin should be used for 10 to 14 days 5.
- Amoxicillin is as effective as amoxicillin-clavulanate as a first-line treatment for ABRS for those without a beta-lactam allergy 4.
- For patients with a beta-lactam allergy, appropriate antibiotics include doxycycline or a respiratory fluoroquinolone 4.
- Supportive care for rhinosinusitis, including use of saline irrigation, nasal steroids or antihistamines, and decongestants, may help reduce the severity of symptoms 4.
Treatment of Acute Bacterial Rhinosinusitis in Pediatric Patients
- In children, ABRS is a common infection that carries a potential for serious, life-threatening complications 6.
- Early, effective antibacterial therapy is essential to shorten the duration of infection and illness, and to prevent contiguous infectious involvement of the orbit or central nervous system 6.
- Amoxicillin is customarily used as first-line therapy for uncomplicated ABRS, and second- or third-generation oral cephalosporins may be used as first-line therapy for patients who are allergic to amoxicillin 6.
Treatment of Acute Exacerbation of Chronic Rhinosinusitis
- The management of acute exacerbation of chronic rhinosinusitis (AECRS) is still under debate, and there are no adequate studies to support a best-evidence treatment for this condition 7.
- A prospective, double-blinded, placebo-controlled trial found that amoxicillin-clavulanate did not change the clinical course of AECRS compared with placebo 7.
- The addition of an oral antibiotic to ongoing topical intranasal steroid spray may not provide additional benefit during management of AECRS 7.