Treatment of Acute Bacterial Rhinosinusitis in Children and Adults
The guideline includes a management algorithm, with recommendations for treating patients who do not respond to initial empirical therapy.
Target Population: Primary care practitioners, especially those in community and emergency department settings
Sponsoring Organization: Infectious Diseases Society of America
Type: Evidence-based consensus guidelines using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system
Key Points: Acute rhinosinusitis (also called sinusitis) is an extremely common condition, each year affecting >10% of adults in the U.S. Despite a viral cause in 90% to 98% of cases, the syndrome is usually treated with antibiotics. To minimize inappropriate antibiotic prescription, these guidelines recommend using symptom persistence (≥10 days), high severity, or worsening/recurrence as indicators of bacterial etiology before empirical therapy is initiated.
Management strategies for bacterial rhinosinusitis are summarized in an algorithm, with recommendations for treating patients who do not respond to initial empirical therapy. Amoxicillin-clavulanate is suggested as initial empirical therapy for both children and adults. For patients with penicillin allergy, the alternatives are doxycycline, levofloxacin, or moxifloxacin in adults, and levofloxacin or a combination of clindamycin and a third-generation oral cephalosporin in children. Macrolides, trimethoprim-sulfamethoxazole, and monotherapy with second- or third-generation cephalosporins are not recommended as empirical therapy because of high resistance rates in Streptococcus pneumoniae. Antistaphylococcal drugs, decongestants, and antihistamines are not recommended, but intranasal steroids may be helpful in patients with a history of allergic rhinitis. Recommended duration of treatment is 5 to 7 days in adults and 10 to 14 days in children. Paranasal sinus imaging by computed tomography is recommended only if suppurative complications are suspected. At that juncture, referral to an otorhinolaryngologist or infectious diseases specialist is advised.
Comment: Rhinosinusitis is a major cause of morbidity in adults, and the overuse of antibiotics for this condition no doubt contributes to increasing antimicrobial resistance in nasopharyngeal flora. Adherence to these very sensible guidelines would go a long way toward decreasing unnecessary antibiotic prescription.