When should antibiotics be prescribed for acute bacterial rhinosinusitis in patients, considering factors such as symptom severity, age, and immune status?

Antibiotic Prescribing for Acute Bacterial Rhinosinusitis

Reserve antibiotics for patients meeting one of three specific criteria: persistent symptoms beyond 10 days without improvement, severe symptoms (fever >39°C with purulent discharge and facial pain for ≥3 consecutive days), or "double-sickening" (worsening after initial improvement within 5-10 days). 1

Clinical Criteria for Bacterial Infection

The diagnosis of acute bacterial rhinosinusitis (ABRS) requires meeting one of these three presentations 2, 3:

• Persistent symptoms: Nasal discharge, congestion, facial pain/pressure, or cough lasting ≥10 days without clinical improvement 1
• Severe onset: High fever (>39°C) plus purulent nasal discharge or facial pain lasting at least 3 consecutive days 1, 4
• Double-sickening: Initial improvement followed by worsening symptoms after 5 days of a typical viral illness 1, 2

Additional supportive findings include purulent nasal discharge, nasal obstruction, maxillary tooth pain, and unilateral sinus tenderness 2. However, colored nasal discharge alone does not indicate bacterial infection 4.

When to Withhold Antibiotics

Most cases of acute rhinosinusitis are viral and self-limited, resolving without antibiotics even when bacterial. 1 The number needed to treat with antibiotics is 18 for one patient to benefit, while the number needed to harm is only 8 1.

Avoid antibiotics in these situations 1, 4:

• Symptoms lasting <7-10 days 4, 5
• Mild symptoms without meeting bacterial criteria 4
• Colored nasal discharge as the sole finding 4
• Viral upper respiratory infection without the three defining criteria 1

Initial Management Strategy

For patients with mild-to-moderate symptoms who meet bacterial criteria but lack risk factors, watchful waiting with symptomatic treatment is the preferred initial approach 2, 3. This includes 2, 4:

• Saline nasal irrigation (physiologic or hypertonic) 3
• Analgesics for pain and antipyretics for fever 1
• Short-term oral or topical decongestants (≤3-5 days to avoid rebound congestion) 2, 6
• Intranasal corticosteroids, especially with allergic component 4, 3

Antibiotic Selection When Indicated

First-Line Therapy

Amoxicillin-clavulanate is the preferred first-line agent according to the Infectious Diseases Society of America 3. However, there is debate among professional societies:

• Standard approach: Amoxicillin-clavulanate for most patients 1, 3
• Alternative view: Plain amoxicillin (1.5-4g/day) is equally effective for patients without recent antibiotic use or risk factors for resistance 4, 7

The IDSA recommends amoxicillin-clavulanate based on concern for ampicillin-resistant Haemophilus influenzae and Moraxella catarrhalis, though no direct evidence proves superiority over amoxicillin 1.

Dosing Strategy

• Standard-dose amoxicillin-clavulanate: For mild disease without resistance risk factors 3
• High-dose amoxicillin-clavulanate: For areas with high penicillin-resistant S. pneumoniae prevalence, moderate disease, or patients with resistance risk factors 3

Penicillin-Allergic Patients

For beta-lactam allergy 1, 4, 3:

• Doxycycline (preferred alternative) 1, 4
• Respiratory fluoroquinolones (levofloxacin, moxifloxacin) 1, 3
• Trimethoprim-sulfamethoxazole 4, 6

Treatment Duration

• Adults: 5-7 days for uncomplicated ABRS 3
• Children: 10-14 days 3
• Traditional approach: 10-14 days until symptom-free plus 7 additional days 8, 6

Risk Factors Requiring Broader Coverage

Consider high-dose amoxicillin-clavulanate or broader-spectrum agents for 2, 3:

• Age <2 or >65 years 2
• Recent antibiotic use within 4-6 weeks 3, 6
• Recent hospitalization 2
• Comorbidities or immunocompromised state 2
• Moderate-to-severe symptoms 3

Do not routinely cover for Staphylococcus aureus (including MRSA) during initial empiric therapy 3.

Reassessment and Treatment Failure

Reassess patients at 3-5 days (or 72 hours) of initial management 2, 4. If no improvement:

• For patients on symptomatic treatment: Consider starting antibiotics 2
• For patients on antibiotics: Switch to broader-spectrum coverage 4
• Consider ceftriaxone 1g IM/IV daily for 5 days for severe infections or treatment failures 4

When to Refer

Refer to a specialist (otolaryngologist, infectious disease, or allergist) for 3:

• Seriously ill patients 3
• Immunocompromised patients 3
• Continued deterioration despite extended antibiotic therapy 3
• Recurrent episodes 3
• Concern for complications (orbital cellulitis, meningitis, abscess) 7

Critical Pitfalls to Avoid

• Overtreatment: 85-98% of clinically suspected cases receive antibiotics, but most are viral 4
• Imaging for uncomplicated cases: Not recommended due to high prevalence of abnormal findings in viral rhinosinusitis 3
• Prolonged decongestant use: Limit topical decongestants to 3-5 days 2, 6
• Antihistamines and oral decongestants: Not recommended by some guidelines 3