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Guidelines Summary

The guidelines by the American Academy of Otolaryngology--Head and Neck Surgery Foundation recommend watchful waiting for initial management of all patients with uncomplicated acute bacterial rhinosinusitis, regardless of severity,^[34]and not just for those with "mild" illness.^[33] The preferred agent when antibiotics are prescribed is amoxicillin with or without clavulanate,^[34] whereas the previous guideline called for amoxicillin alone.^[33]

Other recommendations include the following^[34]:

Clinicians should not obtain radiographic imaging in patients who meet diagnostic criteria for acute rhinosinusitis, unless a complication or alternative diagnosis is suspected.
Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis or acute bacterial rhinosinusitis (ABRS).
If the patient fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management, the clinician should reassess the patient to confirm ABRS, to exclude other causes of illness, and to detect complications. If ABRS is confirmed in a patient who was initially managed with observation, the clinician should begin antibiotic therapy. If the patient was initially managed with an antibiotic, the clinician should change the antibiotic.

The United Kingdom National Institute for Health and Care Excellence (NICE) issued guidance on acute sinusitis that recommends:

A high-dose nasal corticosteroid could be considered for adults and children aged 12 years and over presenting with prolonged symptoms of acute sinusitis.
An antibiotic prescription should not be offered to people presenting with acute sinusitis symptoms for around 10 days or less. Back-up antibiotic prescription could be used if symptoms worsen rapidly or significantly, or do not improve within the next 7 days.
A narrow-spectrum antibiotic phenoxymethylpenicillin as the first choice.
Co-amoxiclav as the first-choice antibiotic for people presenting at any time who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high risk of complications.
Doxycycline or clarithromycin (or erythromycin in pregnancy), can be used as an lternative first-choice antibiotics for use in penicillin allergy or phenoxymethylpenicillin intolerance.

Medication

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NCHS. National Ambulatory Medical Care Survey: 2018 National Summary Tables. The Ambulatory and Hospital Care Statistics Branch at the National Center for Health Statistics (NCHS). Available at https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2018-namcs-web-tables-508.pdf. 2018; Accessed: August 14, 2023.
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Media Gallery

Sagittal section of the lateral nasal wall demonstrating openings of paranasal sinuses. Conchae have been cut to depict details of meatal structures.
Air-fluid level (arrow) in the maxillary sinus suggests sinusitis.
CT cuts for a limited CT study.

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Table 1. Dosage, Route, and Spectrum of Activity of Commonly Used First-Line Antibiotics*

Antibiotic	Dosage	*Streptococcus pneumoniae*			*Haemophilus influenzae*	*Moraxella catarrhalis*	Anaerobic bacteria
Antibiotic	Dosage	Sensitive	Intermediate	Resistant	*Haemophilus influenzae*	*Moraxella catarrhalis*	Anaerobic bacteria
Amoxicillin	500 mg PO tid	+++	++	+	++	+	+++ (except beta-lactamase producers)
Clarithromycin	250-500 mg PO bid	++	++	+	++	+++	+
Azithromycin	500 mg PO first day, then 250 mg/d PO for 4 days	++	++	+	++	+++	+
*+, low activity against microorganism; ++, moderate activity against microorganism; +++, good activity against microorganism

Table 2. Dosage, Route, and Spectrum of Activity of Commonly Used Second-Line Antibiotics*

Antibiotic	Dosage	*Streptococcus pneumoniae*			*Haemophilus influenzae*	*Moraxella catarrhalis*	Anaerobic bacteria
Antibiotic	Dosage	Sensitive	Intermediate	Resistant	*Haemophilus influenzae*	*Moraxella catarrhalis*	Anaerobic bacteria
Amoxicillin/ clavulanate	500 mg PO tid	+++	++	+	+++	+++	+++
Cefuroxime	250-500 mg PO bid	+++	++	+	+++	++	++
Cefpodoxime + cefixime	200 mg PO bid 400 mg/d PO	- ++	+++ -	++ -	+ +++	+++ +++	++ -
Ciprofloxacin	500-750 mg PO bid	++	+	+	++	+++	+
Levofloxacin	500 mg/d PO	+++	+++	+++	+++	+++	++
Trovafloxacin	200 mg/d PO	+++	+++	+++	+++	+++	+++
Clindamycin	300 mg PO tid	+++	+++	++	-	-	+++
Metronidazole	500 mg PO tid	-	-	-	-	-	+++
*+, low activity against microorganism; ++, moderate activity against microorganism; +++, good activity against microorganism; -, no activity against microorganism

Table 3. Dosage, Route, and Spectrum of Activity of Commonly Used Intravenous Antibiotics (Second-Line)*

Antibiotic	Dosage	Streptococcus pneumoniae †	*Haemophilus influenzae*	*Moraxella catarrhalis*	Gram-negative	Anaerobic bacteria
Piperacillin	3-4 g IV q4-6h	+++	+	-	+++	+++
Piperacillin/tazobactam	3.375 g IV q6h	+++	+++	+++	+++	++
Ticarcillin	3 g IV q4h	+++	-	-	+++	++
Ticarcillin/clavulanate	3.1 g IV q4h	+++	+++	-	+++	++
Imipenem	500 mg IV q6h	+++	+++	+++	+++	+++
Meropenem	1 g IV q8h	+++	+++	+++	+++	+++
Cefuroxime	1 g IV q8h	+++	+++	+++	++	++
Ceftriaxone	2 g IV bid	+++	+++	+++	+++	++
Cefotaxime	2 g IV q4-6h	+++	+++	+++	+++	++
Ceftazidime	2 g IV q8h	+++	+++	+++	+++	++
Gentamicin	1.7 mg/kg IV q8h	-	+++	+++	++	-
Tobramycin	1.7 mg/kg IV q8h	-	+++	+++	++	-
Vancomycin	1 g IV q6-12h	+++	-	-	-	++
*+, low activity against microorganism; ++, moderate activity against microorganism; +++, good activity against microorganism; -, no activity against microorganism †Does not take into account penicillin-resistant types.

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Author

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, The Society of Federal Health Professionals (AMSUS), Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, Society for Ear, Nose and Throat Advances in Children, American Federation for Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Brian E Benson, MD, FACS Founding Chair, Department of Otolaryngology-Head and Neck Surgery, Hackensack Meridian School of Medicine; Chief, Division of Laryngeal Surgery, Interim Chair, Department of Otolaryngology-Head and Neck Surgery, Attending Surgeon, Hackensack University Medical Center; Co-Chief, Division of Head and Neck Oncology, The John Theurer Cancer Center at Hackensack University Medical Center

Brian E Benson, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, New York Head and Neck Society, New York Laryngological Society

Disclosure: Nothing to disclose.

Linas Riauba, MD Assistant Professor of Clinical Medicine, Department of Medicine, Section of Infectious Disease, University Hospital, University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Linas Riauba, MD is a member of the following medical societies: American Medical Association, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgements

Michael Cunningham, DO Sr Clinical Instructor, Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry

Michael Cunningham, DO is a member of the following medical societies: American College of Emergency Physicians, American Osteopathic Association, Medical Society of the State of New York, and National Association of EMS Physicians

Disclosure: Nothing to disclose.

Tracey Quail Davidoff, MD Senior Clinical Instructor, Department of Emergency Medicine, Rochester General Hospital

Tracey Quail Davidoff, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Forensic Examiners, American College of Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Thomas E Herchline, MD Professor of Medicine, Wright State University Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, and Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

Erhun Serbetci, MD Director, Department of Otolaryngology, Section of Nose and Sinus Surgery, Associate Professor, International Hospital of Istanbul, Turkey

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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