Medical Treatment for Acute Sinusitis Guidelines

Guidelines for the management of acute sinusitis in adults have been released by the following organizations:

• American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) (2015)
• American Academy of Allergy, Asthma & Immunology (AAAAI)/The American College of Allergy, Asthma & Immunology (ACAAI) (2014)
• Infectious Diseases Society of America (IDSA) (2012)
• University of Michigan Health System (2011)

Diagnosis

The 2014 AAAAI/ACAAI practice parameter provides the following classification for rhinosinusitis ^[13] :

Acute rhinosinusitis (ARS)

Some or all of the following symptoms must exist for less than 12 weeks:

• Persistent upper respiratory infection
• Purulent rhinorrhea
• Postnasal drainage
• Anosmia
• Nasal congestion
• Facial pain
• Headache
• Fever
• Cough

Recurrent acute rhinosinusitis ​ (RARS)

The patient must have had at least 3 episodes of ARS in 12 months.

Chronic rhinosinusitis (CRS)

The patient must have ARS symptoms of varying severity that have lasted longer than 12 weeks.

AAO-HNSF guidelines

In its 2015 updated clinical practice guidelines for management of adult sinusitis, the AAO-HNSF made a strong recommendations that clinicians should distinguish between acute rhinosinusitis caused by bacterial sources and those episodes caused by viral upper respiratory infections and noninfectious conditions. Symptoms or signs of acute bacterial rhinosinusitis (ABRS) include one of both of the following ^[14] :

• Purulent nasal drainage accompanied by nasal obstruction 
• Facial pain-pressure-fullness

A clinician should diagnose ABRS when symptoms or signs of ARS either:

• Persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms
• Worsen within 10 days after an initial improvement (double worsening)

In addition, the AAO-HNSF guidelines recommend against radiographic imaging for patients who meet diagnostic criteria for ARS unless a complication or alternative diagnosis is suspected. ^[14]

IDSA guidelines

In the 2012 IDSA guidelines, a diagnosis of ABRS is made in the presence of any of the following clinical presentations ^[15] :

• Onset with persistent symptoms or signs compatible with ARS lasting for at least 10 days without evidence of improvement
• Onset with severe symptoms or signs of high fever (≥39°C) and purulent nasal discharge or facial pain lasting for at least 3-4 consecutive days at the beginning of illness 
• Onset with worsening symptoms characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection that lasted 5-6 days, with the signs and symptoms having initially shown improvement

University of Michigan Health System guidelines

The 2011 University of Michigan Health System guidelines recommend that a sinus computed tomography (CT) scan be performed while the patient is symptomatic. If symptoms of rhinosinusitis persist for more than 3 weeks despite antibiotics or recur more than three times per year. Because CT scans provide much better definition, plain sinus radiography series are not recommended. ^[16]

Treatment

AAO-HNSF guidelines

AAO-HNSF recommendations for treatment include the following ^[14] :

• For both viral and bacterial rhinosinusitis, analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief may be offered to patients

• Offer either watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; watchful waiting should be offered only when there is assurance of follow-up so that antibiotic therapy can be started if the patient's condition fails to improve within 7 days of the diagnosis or if it worsens at any time

• If ABRS is being treated with an antibiotic, amoxicillin, with or without clavulanate, should be first-line therapy for 5-10 days in most adults

• Reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; if ABRS is confirmed in a patient being managed with observation, antibiotic therapy should commence; if the patient is already being managed with an antibiotic, the antibiotic should be changed

• Distinguish chronic rhinosinusitis and RARS from isolated episodes of ABRS and other causes of sinonasal symptoms

• Assess the patient with chronic rhinosinusitis or RARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia

• Obtain testing for allergy and immune function in a patient with RARS.

IDSA guidelines

In contrast to the AAO-HNSF guideline, the IDSA guidelines recommend initiation of antimicrobial therapy with amoxicillin-clavulanate rather than amoxicillin alone, as soon as the clinical diagnosis of ABRS is established. Either doxycycline or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) is recommended as an alternative agent for empiric antimicrobial therapy in adults who are allergic to penicillin. ^[15] However, in 2016 the US Food and Drug Administration (FDA) issued an advisory that the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with sinusitis and that fluoroquinolones should be reserved for patients who do not have alternative treatment options. ^[17]  Patients who clinically worsen after 3 days of empiric antimicrobial therapy with a first-line agent or who do not improve after 3-5 days of such treatment should be evaluated for the possibility of resistant pathogens, a noninfectious etiology, a structural abnormality, or other causes for treatment failure. ^[15]

Additionally, the IDSA recommends intranasal saline irrigation and intranasal corticosteroids as adjunct treatments. ^[15]

AAAAI/ACAAI guidelines

The 2014 AAAAI/ACAAI practice parameter recommends the use of intranasal corticosteroid as monotherapy or with an antibiotic, for treatment of ABRS. ^[13]

University of Michigan Heath System

The University of Michigan Heath System ABRS treatment recommendations include ^[16] :

• Amoxicillin and trimethoprim/sulfamethoxazole as first-line agents
• First-line alternatives (eg, doxycycline, azithromycin) should only be given to patients allergic to both first line drugs
• The initial course of antibiotics should be 10-14 days, except for azithromycin, which should be prescribed for 3 days
• For partial, but incomplete, resolution after an initial course of antibiotics, extend the duration of antibiotic therapy by an additional 7-10 days for a total of 3 weeks of antibiotics
• For minimal or no improvement with initial treatment, reevaluate the diagnosis and consider changing to an antibiotic with broader coverage that includes resistant strains; options include amoxicillin at high dose, amoxicillin-clavulanate, levofloxacin, and moxifloxacin
• Ciprofloxacin should be avoided due to limited activity against  Streptococcus pneumoniae
• Avoid telithromycin, because risks for hepatotoxicity, loss of consciousness, and visual disturbances may outweigh potential benefits for ABRS.

Pediatric management

In 2013, the American Academy of Pediatrics (AAP) released clinical practice guidelines for the diagnosis and management of acute bacterial sinusitis in children. According to the guidelines, a diagnosis of acute bacterial sinusitis should be made when a child with an acute upper respiratory tract infection (URI) presents with persistent illness (ie, nasal discharge and/or daytime cough) lasting more than 10 days without improvement; a worsening course or new onset of nasal discharge, daytime cough, or fever after initial improvement; or severe onset (ie, fever and purulent nasal discharge) for at least 3 consecutive days. ^[18]

Other key action statements include the following ^[18] :

• Imaging studies (plain films, contrast-enhanced CT scans, magnetic resonance imaging [MRI] scans, or ultrasonograms) are not recommended to distinguish acute bacterial sinusitis from viral URI 
• A contrast-enhanced CT scan of the paranasal sinuses and/or an MRI scan with contrast should be performed if orbital or central nervous system complications are suspected
• Prescribe antibiotic therapy for acute bacterial sinusitis in children with a severe onset or worsening course (signs, symptoms, or both)
• Prescribe antibiotic therapy or offer additional outpatient observation for 3 days to children with persistent illness (nasal discharge of any quality and/or cough for at least 10 days without evidence of improvement) 
• Prescribe amoxicillin, with or without clavulanate, as first-line treatment when a decision has been made to initiate antibiotic therapy 
• Reassess initial management if there is either a caregiver report of worsening or failure to improve within 72 hours of initial management
• If the diagnosis of acute bacterial sinusitis is confirmed in a child with worsening symptoms or failure to improve in 72 hours, then antibiotic therapy may be changed for patients initially managed with antibiotic or antibiotic treatment may be started for patients initially managed with observation

The 2014 AAAAI/ACAAI practice parameter recommends that clinician's look for the presence of otitis media when evaluating a patient with rhinosinusitis. The AAAAI/ACAAI also notes there is no evidence to support the use of nasal irrigations, antihistamines, decongestants, or mucolytics as ancillary therapy in the treatment of ABRS in children. ^[13]

International guidelines

In 2017, the Korea Centers for Disease Control and Prevention released guidelines for antibiotic use in adults aged 19 years or above with acute upper respiratory infections, including the following for cases of acute sinusitis ^[19] :

• Antibiotics may be prescribed early after diagnosis of acute bacterial sinusitis
• Empirical antimicrobial therapy should be initiated when the patient shows no improvement of symptoms within 7 days of diagnosis of acute bacterial sinusitis or shows exacerbation of symptoms
• Antimicrobial therapy should be initiated when the patient shows the following severe symptoms or examination findings: fever of greater than 39°C (102°F), facial pain, or purulent nasal discharge lasting 3-4 days
• Amoxicillin or amoxicillin/clavulanate are recommended for initial empirical therapy for acute bacterial sinusitis in adults
• High doses of amoxicillin or amoxicillin/clavulanate should be considered for patients in areas with high prevalence of penicillin-resistant S pneumoniae, patients with severe symptoms, older patients, patients with recent hospital admission, patients with a history of antimicrobial therapy within the past month, and immunocompromised patients
• For patients with type IV hypersensitivity to penicillin (eg, rash), doxycycline or fluoroquinolones or third-generation cephalosporins or clindamycin may be considered
• For type I hypersensitivity to penicillin (eg, anaphylaxis), all beta-lactam antibiotics (eg, cephalosporins) should not be used; non–beta-lactam antibiotics should be used
• Empirical antibiotic therapy should be maintained for a short period (within 5-10 days or 4-7 days of symptom/sign improvement) unless the patient has severe acute sinusitis
• Second-line therapy should be considered when patients' symptoms worsen within 72 hours of initial empirical therapy or when patients show no improvement even after 3–5 days of treatment
• Drugs such as ampicillin/sulbactam, ceftriaxone, cefotaxime, levofloxacin, and moxifloxacin may be used for severe conditions that require hospitalization
• Surgical treatment may be considered when recurrent acute sinusitis is nonresponsive to appropriate drug therapy