Acute Rhinosinusitis Empiric Therapy 

Updated: Oct 08, 2015
  • Author: Shipra Gupta, MD; Chief Editor: Thomas E Herchline, MD  more...
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Empiric Therapy Regimens

Empiric management of a patient presenting with signs and symptoms of acute rhinosinusitis is discussed below, with a focus on supportive therapy, indications for and choice of antimicrobials, and special circumstances related to the pediatric patient, penicillin-allergic patient, risk for antibiotic resistance, failure of initial therapy, and severe illness.

Adult patients

Supportive therapy for acute rhinosinusitis includes the following:

  • Analgesics/antipyretics for pain and fever
  • Intranasal saline irrigation [1]
  • Short-term use of intranasal steroids is beneficial, especially in patients with allergic rhinitis [2, 3]
  • Topical nasal or systemic over-the-counter decongestants and antihistamines are no longer recommended

Acute bacterial rhinosinusitis

Presence of one of the following suggests the diagnosis of acute bacterial rhinosinusitis:

  • Persistent symptoms or signs of acute rhinosinusitis for 10 or more days with no clinical improvement
  • New onset of fever, headache, and nasal discharge following improvement of initial symptoms
  • Severe symptoms or high fever (>39°C) and facial pain or purulent nasal discharge for at least 3-4 consecutive days

Along with supportive management of symptoms, the following risk factors for antibiotic resistance should be considered for appropriate choice of antimicrobials:

  • Age older than 65 years
  • Recent antibiotic use (within the past month)
  • Recent hospitalization (within the past 5 days)
  • Immunocompromised host
  • Residing in geographic regions with high rates of invasive infections with penicillin-resistant Streptococcus pneumoniae (≥10%)
  • Presence of medical comorbidities

Antimicrobial regimens for acute bacterial rhinosinusitis in adults [4]

No risk factor for antibiotic resistance and no beta-lactam allergy:

  • Amoxicillin-clavulanate (500 mg/125 mg PO tid or 875 mg/125 mg PO bid)

Concern for antibiotic resistance or failed initial therapy or severe infection not requiring hospitalization (systemic symptoms: Fever ≥39°C or risk of suppurative complications); no beta-lactam allergy:

  • Amoxicillin-clavulanate (2000 mg/125 mg PO bid)
  • Doxycycline (100 mg PO bid or 200 mg PO qd)
  • Levofloxacin (500 mg PO qd)
  • Moxifloxacin (400 mg PO qd)

Beta-lactam allergy:

  • Doxycycline (100 mg PO bid or 200 mg PO qd)
  • Levofloxacin (500 mg PO qd)
  • Moxifloxacin (400 mg PO qd)

Severe infection requiring hospitalization:

  • Ampicillin-sulbactam (1.5-3 g ampicillin plus sulbactam component IV every 6 h)
  • Levofloxacin (500 mg PO or IV qd)
  • Moxifloxacin (400 mg PO or IV qd)
  • Ceftriaxone (1-2 g IV q12-24h); max 4 g/24 h
  • Cefotaxime (2 g IV q4-6h); max 8 g/24 h

Duration of treatment: 5-10 days; longer for severe infection

Pediatric patients  [5, 6]

Diagnosis of acute bacterial sinusitis is made when a child has acute upper respiratory tract infection with one of the following:

  • Persistent nasal discharge (of any quality), daytime cough, or both, lasting for more than 10 days without improvement
  • Worsening symptoms of nasal discharge or new-onset daytime cough, nasal discharge or new-onset fever after having experienced transient improvement of symptoms
  • Severe onset defined as temperature of 39°C or higher and purulent (thick, colored, and opaque) nasal discharge present concurrently for at least 3 consecutive days

Indications for antimicrobialtherapy

In patients with severe onset or those with worsening symptoms, antimicrobial therapy is recommended.

Patients with persistent symptoms have 2 options: (1) antimicrobials can be prescribed or (2) outpatient observation for 3 days can be considered and discussed with the parents in patients with reliable follow-up and contingent planning to start antibiotics anytime if the patient starts to deteriorate or fails to improve at the end of the 3 days.

The above-mentioned observational approach for patients with persistent symptoms cannot be applied if any of the following factors are present:

  • Recent antibiotic use (in the past 4 weeks)
  • Concurrent bacterial infection (eg, pneumonia, group A streptoccocal pharyngitis, acute otitis media, suppurative cervical adenitis)
  • Actual or suspected complications of acute bacterial sinusitis
  • Underlying conditions such as asthma, cystic fibrosis, immunodeficiency, previous sinus surgery, or anatomic abnormalities of the upper respiratory tract

Risk factors for antimicrobial resistance include the following:

  • Age younger than 2 years
  • Daycare attendance
  • Recent antibiotic use (in the past month)
  • Recent hospitalization (within the past 5 days)
  • Immunocompromised children
  • Residing in geographic regions with high rates of invasive infections with penicillin-resistant S pneumoniae (≥10%)

Antimicrobial regimen for acute bacterial rhinosinusitis in children [4]

No risk factors for antibiotic resistance and no beta-lactam allergy:

  • Amoxicillin (45 mg/kg/day PO bid); max dose 4 g/24 h
  • Amoxicillin-clavulanate (45 mg/kg/day PO bid); not exceed amoxicillin dose of 4 g/24 h
  • If greater than 10% of S pneumoniae in community are resistant to penicillin, use a higher dose of amoxicillin (80-90 mg/kg/day PO bid; not to exceed 2 g/dose)
  • Single IM/IV dose of ceftriaxone (50 mg/kg; not to exceed 2 g/dose) can be administered initially to patients who are unable tolerate oral administration, with vomiting, or with poor compliance, until improvement occurs and oral antibiotics can be substituted to complete the remaining course

Concern for antibiotic resistance or failed initial therapy; no beta-lactam allergy:

  • Amoxicillin-clavulanate (80-90 mg/kg/day PO bid; not exceed amoxicillin dose of 4 g/24 h)
  • Clindamycin (30-40 mg/kg/day PO tid; max dose 1.8 g/day) plus cefixime (8 mg/kg/day PO bid; max dose 400 mg/24 h) or cefpodoxime (10 mg/kg/day PO bid; max dose 400 mg/24 h)
  • Linezolid (age <12 y, 30 mg/kg/day PO tid; age >12 y, 30 mg/kg/day PO bid; not to exceed 600 mg/dose) plus cefixime (8 mg/kg/day PO bid; max dose 400 mg/24 h) or cefpodoxime (10 mg/kg/day PO bid; max dose 400 mg/24 h)

Beta-lactam allergy:

  • Type I hypersensitivity: Levofloxacin (10-20 mg/kg/day PO q12-24h; max dose 500 mg/24 h)
  • Non–type I hypersensitivity: Clindamycin (30-40 mg/kg/day PO tid; max dose 1.8 g/day) plus cefixime (8 mg/kg/day PO bid; max dose 400 mg/24 h) or cefpodoxime (10 mg/kg/day PO bid; max dose 400 mg/24 h) OR
  • Non–type I hypersensitivity: Linezolid  (age <12 y, 30 mg/kg/day PO tid; age >12 y, 30 mg/kg/day PO bid; not to exceed 600 mg/dose) plus cefixime (8 mg/kg/day PO bid; max dose 400 mg/24 h) or cefpodoxime (10 mg/kg/day PO bid; max dose 400 mg/24 h)

Severe infection requiring hospitalization:

  • Ampicillin/sulbactam (200-400 mg/kg/day IV q6h; max dose 8 g ampicillin/24 h)
  • Ceftriaxone (50 mg/kg/day IV q12h; max dose 4 g/24 h)
  • Cefotaxime (100-200 mg/kg/day IV q6h; max dose 8 g/24 h)
  • Levofloxacin (10-20 mg/kg/day IV every 12-24 h; max dose 500 mg/24 h)

Duration of treatment: 7 days after patient is symptom free, with minimum of 10 days of therapy; longer in patients with severe infection.

Adjuvant therapy

In the pediatric population, a recent Cochrane Review did not show any well-designed studies to determine the effectiveness of adjuvant therapy such as nasal decongestants, mucolytics, nasal irrigation, and/or antihistamines. [7]

Intranasal steroids can be used as an adjunct to antibiotics in the empiric treatment of acute bacterial rhinosinusitis, primarily in patients with a history of allergic rhinitis.