Acute Bacterial Rhinosinusitis

Principles of appropriate antibiotic use for acute rhinosinusitis apply to the diagnosis and treatment
of acute maxillary and ethmoid rhinosinusitis in otherwise healthy adults.

Sinus inflammation is often viral and usually resolves without antibiotics.

Background
Respiratory viruses typically cause
inflammation of the nasal mucosa and
maxillary sinuses.
Most cases of acute rhinosinusitis are
due to uncomplicated viral infections.
Diagnosis
Most rhinovirus colds last 7 to 11 days
(J Clin Microbiol 1997; 35:2864; JAMA 1967;
202:158).
Bacterial rhinosinusitis may be present
if symptoms have been present >7 days
and there is localization to the maxillary
sinus.
Treatment
Patients may rarely present with severe
symptoms of bacterial rhinosinusitis less TIPS TO REDUCE
than 7 days duration (acute focal
sinusitis). Consider immediate referral to ANTIBIOTIC USE
an otolaryngologist for evaluation and Tell patients that anti-
drainage. biotic use increases the
Sinus radiography is not recommended risk of an antibiotic-
for routine evaluation of acute, resistant infection.
uncomplicated bacterial rhinosinusitis. Identify and validate
Opacification and air-fluid level have patient concerns.
sensitivity of ~ 73% and specificity
of 80% (J Clin Epidemiol 2000;53:852). Recommend specific
symptomatic therapy.
Mucosal abnormalities are common in
patients with viral infections (J Allergy
Clin Immunol 1998;102:403). Spend time answering
questions and offer a
contingency plan if
symptoms worsen.

Signs/Symptoms of Most patients with acute bacterial Provide patient educa-

rhinosinusitis improve without antibiotic tion materials on
Acute Maxillary Sinusitis treatment. antibiotic resistance.
(BMJ 1995;311:233) About 81% of antibiotic-treated patients
and 66% of controls are improved at REMEMBER: Effective
Maxillary communication is more
10-14 days (absolute benefit of 15%).
Sinusitis important than an
Present Absent Odds Patients with mild symptoms should not antibiotic for patient
(N=92) (N=82) Ratio receive antibiotics, but symptomatic satisfaction.
treatment may be helpful.
Fever 89% 79% 2.1 Topical and oral decongestants may See www.cdc.gov/
Unilateral 51% 38% 1.9 reduce nasal symptoms. drugresistance/community
maxillary Most randomized trials of symptomatic or contact your local
pain therapies have been inconclusive. health department for
more information and
Maxillary 66% 51% 1.9 Patients with moderate or severe symp- patient education materials.
toothache toms may benefit from antibiotics.
Unilateral 49% 32% 2.5 Use a narrow spectrum agent that
maxillary covers S. pneumoniae and H. influenzae.
sinus Amoxicillin remains an appropriate
tenderness choice for uncomplicated infections.
Consider second line agent if no
Key Reference
Hickner JM et al. Principles of
Generalized facial pain or tenderness, improvement or worsening after
appropriate antibiotic use for acute
postnasal drainage, headache, and cough 72 hours.
rhinosinusitis in adults: Background.
do not increase the predictive value of Annals of Internal Medicine 2001;
maxillary sinus symptoms. 134(6):498-505.