Version July 2025
INTRODUCTION —
Acute rhinosinusitis (ARS) is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses (figure 1) lasting less than four weeks. The term "rhinosinusitis" is preferred to "sinusitis" since inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa [1].
The most common etiology of ARS is a viral infection. The clinical manifestations and diagnosis of ARS are discussed separately. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis".)
Treatment for acute viral rhinosinusitis (AVRS) focuses on symptomatic management, as it typically resolves within 7 to 10 days. Bacterial infection occurs in only 0.5 to 2 percent of episodes of ARS [2]. Acute bacterial rhinosinusitis (ABRS) may also be a self-limited disease. Patients may be treated symptomatically and observed or treated with antibiotics. Rarely, patients with ABRS develop serious complications.
This topic will address the treatment of uncomplicated ARS. The treatment of complications of ABRS are discussed in the appropriate topics. As examples:
●Orbital cellulitis (see "Orbital cellulitis")
●Preseptal (periorbital) cellulitis (see "Preseptal cellulitis")
●Intracranial abscess (see "Treatment and prognosis of bacterial brain abscess")
●Meningitis (see "Initial therapy and prognosis of community-acquired bacterial meningitis in adults")
The treatment of nosocomial bacterial sinusitis and acute invasive fungal sinusitis are also discussed separately. (See "Fungal rhinosinusitis", section on 'Treatment' and "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Sinusitis'.)
INITIAL MANAGEMENT FOR ALL PATIENTS —
Symptomatic therapy is the mainstay of treatment for acute rhinosinusitis (ARS), as most infections are self-limited regardless of viral or bacterial etiology. Initial evaluation involves identifying complicated infection, which warrants urgent management, and identifying bacterial infection, which warrants antibiotic therapy in selected patients. (See 'Antibiotic therapy for selected individuals' below.)
Identify alarm symptoms — All patients with ARS should be evaluated for alarm symptoms indicating complicated infection; these patients warrant urgent imaging and otolaryngology evaluation, typically in an emergency department setting (algorithm 1). Symptoms indicating complicated infection include:
●Periorbital edema, inflammation, or erythema
●Cranial nerve palsies
●Abnormal extraocular movements
●Pain with eye movement
●Proptosis
●Vision changes (double vision or impaired vision)
●Severe and persistent headache
●Altered mental status
●Meningeal signs
●Signs of increased intracranial pressure (eg, nausea, vomiting, papilledema)
High, persistent fevers (eg, fever >102°F for longer than 24 hours) are not specific for complicated acute bacterial rhinosinusitis (ABRS), but we have a low threshold to obtain imaging in these patients to rule out complications.
Evaluation of patients with complicated ABRS varies by suspected diagnosis and is described in detail elsewhere (table 1). (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Complications' and "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Complicated acute bacterial rhinosinusitis'.)
Identify features suggestive of bacterial infection — Because alternate management may be warranted in patients with bacterial infection, it is important to identify these patients at the time of presentation (algorithm 1). A clinical diagnosis of ABRS can be made in patients who have (table 2):
●Persistent ARS symptoms for at least 10 days without improvement; or
●A biphasic pattern of illness (ie, initial improvement with worsening five to six days later)
Additional clinical features distinguishing acute bacterial sinusitis are discussed in detail elsewhere. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Acute bacterial rhinosinusitis'.)
Preferred symptomatic therapy — For patients with ARS who do not have alarm symptoms, we suggest over-the-counter analgesics, antipyretics, and saline irrigation for symptomatic management (table 3). In addition, some experts, including the author of this topic, routinely use intranasal glucocorticoids for all patients with ARS, although other contributors use this more selectively. Symptomatic management of ARS, both viral and bacterial in etiology, aims to relieve symptoms of nasal obstruction and rhinorrhea as well as systemic signs such as fever.
Analgesics and antipyretics — For pain and fever associated with ARS, over-the-counter analgesics and antipyretics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are generally sufficient [3,4].
Saline nasal irrigation — We suggest saline nasal irrigation with buffered, physiologic, or hypertonic saline to reduce the need for pain medication and improve overall patient comfort, particularly in patients with frequent sinus infections. It is important that irrigants be prepared from sterile or bottled water, as there have been reports of amebic encephalitis due to tap water rinses [5]. Instructions for preparing a rinse solution are shown in the table (table 4).
The evidence supporting the use of saline irrigation is limited to small trials, most of which do not clearly demonstrate a benefit [6]. However, in our experience, it is often effective in improving nasal symptoms, and overall the adverse effects are minor (eg, nasal burning and irritation), although some patients find it uncomfortable or difficult to perform.
Variable role for intranasal glucocorticoids — Some experts, including the author of this topic, routinely use intranasal glucocorticoids (eg, mometasone or fluticasone) for all patients with ARS, whereas other experts use this more selectively (eg, in patients with concomitant allergic rhinitis or more severe symptoms) because of small benefits. When used in combination with nasal irrigation, intranasal glucocorticoids should be used just after irrigation so that mucosa is freshly cleansed when medication is applied. The theoretic mechanism of action of intranasal glucocorticoids is through a decrease in mucosal inflammation, which allows for improved sinus drainage.
Studies have shown small symptomatic benefits and minimal adverse effects with short-term use of intranasal glucocorticoids for patients with both acute viral rhinosinusitis (AVRS) and ABRS [3,4]. In a meta-analysis of three studies involving patients with ARS diagnosed by symptoms and confirmed by radiologic or endoscopic studies, use of intranasal glucocorticoids increased the rate of symptom response compared with placebo (73 versus 66 percent; risk ratio [RR] 1.11, 95% CI 1.04-1.18) [7]. A higher dose of intranasal glucocorticoids (mometasone 400 mcg versus 200 mcg total daily dose) had a stronger effect on symptom improvement. One of these studies evaluated intranasal glucocorticoids as monotherapy, and two evaluated them as adjuncts to oral antibiotics. When used as an adjunct to antibiotic therapy in the treatment of ABRS, 15 patients would need to be treated with intranasal glucocorticoids to improve clinical symptoms in one patient [4].
Other symptomatic options of uncertain benefit — Additional supportive treatments are frequently used in the symptomatic treatment of ARS, but there are no high-quality studies evaluating their benefit in these patients. Guidance can be tailored based on individual patient preferences and additional comorbidities (eg, oral decongestants for Eustachian tube dysfunction or antihistamines for allergy symptoms).
●Intranasal saline spray – Sterile intranasal saline spray may temporarily improve nasal passage patency by moisturizing and loosening secretions. This approach may be useful in combination with intranasal glucocorticoids. Intranasal saline is generally administered prior to other topical agents when combination intranasal therapy is used, as saline helps clean the mucosa and allows for better penetration of other agents. The major disadvantages are that some patients may find this to be uncomfortable or difficult. Saline must also be sterile.
●Intranasal ipratropium bromide – Intranasal ipratropium bromide is an anticholinergic spray that can help reduce rhinorrhea in patients with concurrent common cold symptoms. It may not have significant effect on nasal congestion. (See "The common cold in adults: Treatment and prevention", section on 'Intranasal ipratropium bromide'.)
●Oral decongestants – Oral decongestants may be useful when Eustachian tube dysfunction is a factor for patients with ARS; this can be suspected if the patient has feelings of ear pressure or fullness. These patients may benefit from a short course (three to five days) of oral decongestants. Oral decongestants should be used with caution in patients with cardiovascular disease, hypertension, angle-closure glaucoma, or bladder neck obstruction [8]. (See "Eustachian tube dysfunction" and "Eustachian tube dysfunction", section on 'Medical management'.)
In patients without Eustachian tube dysfunction, there is no evidence that oral decongestants are efficacious in decreasing symptoms of ARS, and they have many adverse side effects (table 5) [3,4].
●Intranasal decongestants – We do not routinely use intranasal decongestants (eg, oxymetazoline) in the treatment of ARS. Although they may provide a subjective sense of improved nasal patency, there is no evidence to support their efficacy in ARS [3,4]. In addition, they have been shown to provoke mucosal inflammation in an experimental animal model [9], and chronic use causes rhinitis medicamentosa in humans.
If used, topical decongestants should be used sparingly for no more than three consecutive days to avoid rebound congestion, addiction, and mucosal damage associated with long-term use [10,11]. (See "An overview of rhinitis", section on 'Nasal decongestant sprays' and "Chronic nonallergic rhinitis", section on 'Management of rhinitis medicamentosa'.)
●Antihistamines – We do not routinely advise antihistamines unless there is concurrent allergic disease. Although antihistamines are sometimes used for symptom relief due to their drying effects, there are no studies investigating their efficacy for ARS, and they are often associated with adverse effects (eg, drowsiness or xerostomia) [3,4]. In some cases, over-drying of the mucosa may lead to further discomfort. (See "Pharmacotherapy of allergic rhinitis", section on 'Minimally sedating oral antihistamines'.)
●Mucolytics – Mucolytics such as guaifenesin thin secretions may promote ease of mucus drainage and clearance; however, there are no published trials to support their use in ARS [3].
●Steam inhalation or "tenting" – Inhalation of warm, humidified air (steam), may provide patients with a transient sense of relief of congestion, but there is no evidence that it shortens the duration or severity of symptoms [12,13]. If steam is used, care should be taken to ensure that the source of steam is clean, without mold or other contaminants.
Systemic glucocorticoids not indicated — We suggest not using systemic glucocorticoids in the treatment of ARS. When given in addition to antibiotics, oral glucocorticoids may shorten the time to symptom resolution or improvement, but the benefits are small and, unlike topical glucocorticoids, systemic glucocorticoids pose a potential risk for side effects that outweighs the clinical benefits. (See "Major adverse effects of systemic glucocorticoids".)
In a meta-analysis of almost 1200 adults with acute sinusitis, systemic glucocorticoids increased the rate of symptom resolution or improvement at three to seven days compared with placebo (70 versus 54 percent; RR 1.3, 95% CI 1.1-1.6); however, estimated improvement at 4 to 14 days was less certain (78 versus 66 percent; RR 1.2, 9% CI 1.0-1.5) [14]. While this meta-analysis did not demonstrate an increased risk of side effects with systemic glucocorticoids, the included trials were limited by methodologic problems including potential for attrition bias and lack of long-term follow-up on the effects of steroids.
ADDITIONAL MANAGEMENT FOR ACUTE BACTERIAL RHINOSINUSITIS —
In patients with a clinical diagnosis of acute bacterial rhinosinusitis (ABRS) (table 2) (see 'Identify features suggestive of bacterial infection' above), management options include an additional seven-day observation period or initiation of antibiotic therapy.
Continued observation for most patients
Patient selection and approach — For most patients with clinically diagnosed ABRS, we suggest an additional seven-day observation period without antibiotics (ie, "watchful waiting"). In many cases, the observation period may extend to 17 total days (ie, 10 days of symptoms to make a clinical diagnosis of ABRS, then an additional 7-day observation period).
However, there are important exceptions, and patient selection for additional observation depends on immune status, comorbidities, reliability of follow-up, presence of anatomic abnormalities, and age (algorithm 2).
We have a low threshold to initiate antibiotics at the time of diagnosis for patients with any of the following:
●Immunocompromising conditions or comorbidities that can affect immune function (eg, poorly controlled diabetes mellitus)
●Multiple comorbidities
●Unreliable or uncertain follow-up
●Known anatomic abnormalities (eg, congenital abnormalities) that could predispose to easier spread to the eyes or brain
●Younger age (infection can spread more easily through the frontal and orbital bones in patients in their late teens to early twenties)
For patients with any of these features, we individualize the decision of observation versus starting antibiotics and generally have a low threshold to initiate antibiotic treatment at the time of ABRS diagnosis because of the potential for more severe infection.
When observation is selected, we follow up with patients within seven days. If patients worsen during this period, or if they do not improve after seven days, we proceed to antibiotics. In some cases (eg, to save the time and inconvenience of a follow-up visit), we provide patients a prescription for antibiotics at the time of ABRS diagnosis with instructions to fill it only if they worsen or do not improve after seven days.
Antibiotic selection, when warranted, is discussed elsewhere. (See 'Choice of agent' below.)
Rationale — ABRS is often a self-limited disease, and most patients (approximately 65 to 80 percent) with clinically diagnosed ABRS improve without antibiotic therapy [15,16]. In addition, while antibiotics may reduce symptom duration and improve cure rate in ABRS, benefits are small and come with increased adverse effects [4,15,17-19].
●ABRS is often a self-limited disease – Several meta-analyses have demonstrated that ABRS is often a self-limited disease. As an example, in a 2014 meta-analysis of randomized trials in immunocompetent patients with maxillary sinusitis, 80 percent of patients not treated with antibiotics improved within two weeks [15]. In a 2018 meta-analysis of 15 randomized trials including over 3000 immunocompetent patients with uncomplicated acute rhinosinusitis (ARS), nearly half of patients improved by one week, and two-thirds by two weeks, irrespective of antibiotic therapy [16].
●Modest benefits of antibiotics may not outweigh risks – Meta-analyses have consistently found that, compared with placebo, antibiotics result in modestly higher rates of clinical improvement, but come with increased adverse effects [15-19]. As an example, in one meta-analysis, antibiotics improved the rate of cure (58 percent versus 52 percent; odds ratio [OR] 1.4, 95% CI 1.2-1.7), but had an increased risk of side effects (primarily gastrointestinal; 28 percent versus 15 percent; OR 2.2, 95% CI 1.7-2.8) [16]. In one included study of patients with clinically diagnosed ABRS, those who received antibiotics reported improved symptom scores at day 3 compared with those who received placebo (mean symptom score 9.4 versus 11.5 on a 30-point scale); however, by day 10, symptom scores were similar in both groups (5.2 versus 5.4) [20]. Patients who received antibiotics had numerically higher rates of recovery at 14 days (80 percent versus 66 percent) and of side effects (39 percent versus 27 percent), but neither was statistically significant. The mean illness duration was similar in both groups (6 days versus 6.4 days).
Overall, the net benefit of antibiotics taking into account the potential for adverse effects is relatively small. Estimates of the number needed to treat to benefit range from 13 to 18 patients, while the number needed to harm is approximately eight patients [3,4,17,18].
Many of the above-referenced studies are likely to have included patients with acute viral rhinosinusitis (AVRS), as most studies used clinical criteria for diagnosis of ABRS without culture confirmation. Including patients with acute viral rhinosinusitis (AVRS) in these studies likely increased the reported rates of spontaneous recovery, and diminished the reported benefit of antibiotics (ie, a combined population of patients with ABRS and AVRS is less likely to benefit from antibiotic therapy than a more strictly defined ABRS population). In addition, many of the trials included in the meta-analyses excluded patients with pregnancy and immunodeficiency. Some excluded patients with comorbidities such as diabetes, pulmonary disease, and heart failure [21]. Therefore, there are insufficient data to determine if patients with underlying comorbidities benefit from watchful waiting rather than initiation of antibiotics at diagnosis.
●Guidelines differ – Guidelines for the management of sinusitis have been issued by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS; 2015) and the Infectious Disease Society of America (IDSA; 2012).
Our approach of favoring observation in immunocompetent patients with ABRS who have reliable follow-up is consistent with the AAO-HNS 2015 guidelines [3]. The guidelines suggest that factors such as age, general state of health, and comorbidities should be considered when choosing this option.
In contrast, the 2012 IDSA guidelines recommend initiation of antibiotics for any patient who has 10 days of ARS symptoms, a biphasic pattern of illness, or three to four days of severe symptoms (eg, high fever [≥39°C], purulent nasal discharge, or severe facial pain) [4]. It is important to note that the IDSA guidelines preceded several of the meta-analyses described above that support our recommendations [15,16].
Antibiotic therapy for selected individuals — As discussed above, we suggest initial observation in most patients with ABRS (see 'Continued observation for most patients' above). Antibiotics may improve rates of clinical improvement, but the small benefit does not outweigh the risk of adverse effects in all patients. (See 'Rationale' above.).
Antibiotic therapy is appropriate as initial treatment for patients at increased risk for complicated infection, including those with immunocompromising conditions, multiple comorbidities, poor or uncertain follow-up, known anatomic abnormalities, or younger age.
In addition, antibiotic therapy is appropriate for patients who are initially managed with an observation period but have worsening symptoms or have persistent symptoms without improvement at the end of seven days.
Choice of agent — Initial empiric treatment generally includes amoxicillin or amoxicillin-clavulanate; the choice between these agents and dosing depends on risk factors for bacterial resistance (algorithm 3).
Patients without risk factors for resistant pneumococcus — For patients with ABRS without risk factors for resistant pneumococcus (table 6), we suggest treatment with one of the following agents:
●Amoxicillin (500 mg orally three times daily or 875 mg orally twice daily) or
●Standard-dose amoxicillin-clavulanate (500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily)
These agents are effective against the common pathogens associated with ABRS, with a relatively narrow spectrum of activity and few adverse effects.
Both amoxicillin and standard-dose amoxicillin-clavulanate are active against the two most common bacteria associated with ABRS in adults: Streptococcus pneumoniae and Haemophilus influenzae [4]. Amoxicillin-clavulanate additionally provides coverage for beta-lactamase-producing H. influenzae and Moraxella catarrhalis (which almost uniformly produces beta-lactamase). In areas of increased local prevalence of beta-lactamase-producing H. influenzae (or if the local rates are uncertain), we suggest amoxicillin-clavulanate. We also suggest amoxicillin-clavulanate for individuals who smoke or have a smoker in their household, those who work in or have close contacts in a health care environment, and those who have close contact with a child in a daycare facility [3].
Patients with risk factors for resistant pneumococcus — For patients with risk factors for resistant pneumococcus, we suggest high-dose amoxicillin-clavulanate (2 g/125 mg extended-release tablets orally twice daily). Risk factors for resistant pneumococcus include (table 6):
•Living in geographic regions with rates of penicillin-nonsusceptible (PNS) S. pneumoniae exceeding 10 percent. Local and regional histograms of bacterial resistance should be referenced to understand resistance trends in the local community.
•Age ≥65 years
•Hospitalization in the last three months
•Antibiotic use in the last three months
•Immunocompromising condition
•Multiple comorbidities (eg, diabetes or chronic cardiac, hepatic, or kidney disease)
•Severe infection (eg, evidence of systemic toxicity or concern for suppurative complications)
High-dose amoxicillin is necessary in these situations because the mechanism of penicillin resistance in PNS S. pneumoniae is not through beta-lactamase production but rather due to a mutation in penicillin binding protein 3 (PBP3). Thus, beta lactamase inhibitors are not effective; however, the resistance conferred by the mutation in PBP3 can usually be overcome with high-dose amoxicillin. We prefer amoxicillin with clavulanate over high-dose amoxicillin alone because patients with these risk factors typically also have increased risk for beta-lactamase-producing H. influenzae.
Patients with penicillin allergy — For any patient with a penicillin allergy, doxycycline is a reasonable alternative to amoxicillin or amoxicillin-clavulanate for initial therapy. Additional alternatives depend on the severity of the allergy and tolerance of cephalosporins. Most individuals with a history of a penicillin allergy can tolerate a cephalosporin safely, as discussed elsewhere. (See "Choice of antibiotics in penicillin-allergic hospitalized patients".)
●For penicillin-allergic patients who can tolerate cephalosporins – Our preferred options for initial therapy include:
•Doxycycline 100 mg orally twice daily or 200 mg orally daily
•A third-generation oral cephalosporin (cefixime 400 mg daily or cefpodoxime 200 mg twice daily) prescribed with or without clindamycin (300 mg every six hours). Monotherapy with a third-generation cephalosporin is likely adequate for most patients, particularly those without risk factors for resistance. For patients with risk factors for resistance (table 6), the addition of clindamycin to a cephalosporin provides improved coverage for beta-lactam-resistant S. pneumoniae, although this carries an increased risk of adverse effects (eg, Clostridioides [formerly Clostridium] difficile infection).
●For penicillin-allergic patients who cannot use any beta-lactam agents – Our preferred option for initial therapy is:
•Doxycycline 100 mg orally twice daily or 200 mg orally daily
We reserve respiratory fluoroquinolones (levofloxacin 750 mg or 500 mg orally once daily or moxifloxacin 400 mg orally once daily) for those who cannot use any of the above agents, as the risk of serious adverse effects associated with fluoroquinolones generally outweighs the benefits for patients with acute sinusitis [22]. (See "Fluoroquinolones", section on 'Benefits and risks of use'.)
Macrolides (clarithromycin or azithromycin) and trimethoprim-sulfamethoxazole are not recommended for empiric therapy because of high rates of resistance of S. pneumoniae [3,4]. This is discussed in detail elsewhere. (See "Resistance of Streptococcus pneumoniae to the macrolides, azalides, and lincosamides" and "Resistance of Streptococcus pneumoniae to the fluoroquinolones, doxycycline, and trimethoprim-sulfamethoxazole".)
Antibiotic therapy for patients who are pregnant and those with nosocomial sinusitis is discussed separately. (See "Approach to the pregnant patient with a respiratory infection", section on 'Acute sinusitis' and "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Sinusitis'.)
Duration — We suggest an initial antibiotic treatment course of five to seven days. We typically give a prescription for seven days but inform patients they can stop after five days if symptoms have improved. Available evidence suggests that response rates with this duration are similar and associated with fewer adverse events than longer courses [3,4].
In one meta-analysis of 12 randomized trials of ABRS in adults, no difference was noted in response rates or relapse rates comparing short courses (three to seven days) with longer courses (6 to 10 days) of antibiotics [23]. Rates of adverse events were also similar. However, there was heterogeneity in the trials in terms of symptom duration and use of adjunctive medications.
Expected response — Patients typically demonstrate improvement of symptoms within three to five days of starting antibiotic therapy. Older adults and individuals with multiple comorbidities may take longer to completely resolve, but they should show some symptom improvement within five days of initiating antibiotic therapy [4].
Suboptimal response to antibiotic therapy — Reasons for treatment failure include resistant pathogens, inadequate dosing, structural abnormalities, or a noninfectious etiology [4].
Failure of initial therapy — Patients who have worsening symptoms or do not improve with initial antibiotic therapy should have the diagnosis of ABRS confirmed with clinical reevaluation and imaging if needed; we suggest an alternative antibiotic regimen for patients with confirmed uncomplicated ABRS.
Confirmation of diagnosis — For patients who fail to improve with initial therapy, we confirm the diagnosis of uncomplicated ABRS clinically; imaging may be necessary when there is clinical uncertainty or concern for complication.
●Clinical reevaluation – We review the history and physical to confirm that the presentation is consistent with ABRS, with symptoms of severe nasal congestion and/or facial pain or pressure that were not present for more than four weeks at the time of the original ABRS diagnosis. Symptoms of longer duration may be more consistent with chronic rhinosinusitis or allergic rhinitis. Other mimics of ARS include headache syndromes, temporomandibular joint dysfunction, and dental pain; predominant headaches, jaw pain, or tooth pain may suggest these alternative possibilities. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Differential diagnosis'.)
In addition, we assess for signs or symptoms of complicated ABRS during clinical reevaluation (table 1). Untreated ABRS can rarely extend from the sinuses into the orbit, central nervous system, or surrounding tissue. If there are any alarm symptoms, urgent management is necessary. (See 'Identify alarm symptoms' above.)
●Role of imaging – We obtain computed tomography (CT) scan of the sinuses without contrast in patients who do not improve with initial therapy only when the diagnosis of ABRS remains uncertain after clinical reevaluation; imaging can confirm sinusitis, identify a complication (eg, abscess), and evaluate for alternative diagnoses. We have a lower threshold to obtain imaging in patients who were initially treated with a respiratory fluoroquinolone, as fluoroquinolone resistance is rare among pathogens that commonly cause ABRS and treatment failure is more likely due to an alternate diagnosis or anatomic obstruction. (See 'Failure of multiple oral antibiotic courses' below.)
Although CT scan of the sinuses without contrast is appropriate initial imaging in most cases, if the patient has symptoms or findings concerning for a specific complication, choice of imaging modality may differ based on the suspected diagnosis (table 1). (See 'Identify alarm symptoms' above.)
Retreatment with an alternative regimen — For patients whose symptoms worsen or fail to improve after seven days of antibiotic therapy and whose repeat evaluation confirms uncomplicated ABRS, we suggest a repeat course of antibiotics with a regimen that is different from the one initially used.
There are limited data to guide antibiotic selection for patients who do not respond to initial antibiotic treatment [3,4]. In general, subsequent antibiotic therapy should have a broader spectrum of activity and/or be in a different drug class than the initial agent used.
Treatment options include high-dose amoxicillin-clavulanate, a third-generation cephalosporin with clindamycin, or a respiratory fluoroquinolone. These agents have broader coverage and lower rates of resistance compared with amoxicillin or doxycycline.
Specific choice of therapy depends on initial antibiotic therapy:
●Initial amoxicillin – We suggest high-dose amoxicillin-clavulanate for patients who do not improve with initial amoxicillin treatment. Other options include a third-generation cephalosporin with clindamycin or a respiratory fluoroquinolone; however, these are associated with higher rates of serious adverse effects compared with amoxicillin-clavulanate. We do not use doxycycline because it has a narrower spectrum of activity compared with amoxicillin-clavulanate.
●Initial amoxicillin-clavulanate – We suggest a respiratory fluoroquinolone for patients who do not improve with initial amoxicillin-clavulanate therapy (regardless of dose). We do not use a third-generation cephalosporin with clindamycin in these patients because of the possibility of cross-resistance between regimens.
●Initial doxycycline – For patients who do not improve with initial doxycycline, subsequent options are based on whether they have a penicillin allergy, and whether they can tolerate cephalosporins.
•Patients with penicillin allergy – For patients with a penicillin allergy initially treated with doxycycline, we suggest treatment with a respiratory fluoroquinolone. A third-generation cephalosporin with clindamycin is also an option for patients who can tolerate cephalosporins, although there are no studies supporting the efficacy of this regimen in ABRS.
•Patients without penicillin allergy – For patients without a penicillin allergy initially treated with doxycycline, we prefer treatment with high-dose amoxicillin-clavulanate. As described above, amoxicillin-clavulanate has a more favorable risk profile compared with fluoroquinolones and clindamycin.
●Initial third-generation cephalosporin (with or without clindamycin) – We suggest a respiratory fluoroquinolone for patients who do not improve with initial cephalosporin (with or without clindamycin) treatment. As described above, we do not use amoxicillin-clavulanate because of the possibility of cross-resistance between regimens, and we do not use doxycycline due to a narrower spectrum of activity.
For patients initially treated with a fluoroquinolone who do not improve, we generally proceed with imaging and/or referral to an otolaryngology specialist. Fluroquinolone resistance is rare among pathogens that commonly cause ABRS, and failure of treatment is more likely due to a structural abnormality.
We typically treat patients who show improvement during the first week of therapy for 7 to 10 days.
Relapse after initial improvement — Recurrence of symptoms within two weeks of response to initial oral treatment usually represents inadequate eradication of infection or resistance to antibiotic.
●Mild recurrence – Patients who had a good response to initial oral therapy and who have mild symptoms (ie, symptoms less severe than initial presentation) can be treated with a longer course (7 to 10 days) of the same antibiotic. If symptoms persist despite a repeat 7- to 10-day course of antibiotics, confirmation of diagnosis and alternative treatment regimen is warranted (See 'Failure of initial therapy' above.).
●Moderate to severe recurrence – Relapse that is moderate to severe raises concern for resistant organisms. For such patients, we choose an alternative antibiotic regimen and perform imaging if complications or an alternative diagnosis are suspected. (See 'Failure of initial therapy' above.)
Indications for otolaryngology referral — Patients who do not improve after multiple antibiotic courses, and those with recurrent infections, warrant referral to an otolaryngology specialist.
Failure of multiple oral antibiotic courses — Patients with persistent symptoms after two courses of appropriate antibiotic therapy warrant referral to an otolaryngology specialist. Additional evaluation typically includes sinus culture and noncontrast CT imaging of the sinuses if not already performed [3,4]. Sinus culture can be obtained either by direct aspirate or endoscopy of the middle meatus. CT imaging of the sinuses evaluates for anatomic blockage (eg, polyps or septal deviation). Patients with anatomic blockages may require surgical management [24].
Recurrent infections — Patients with frequent episodes of ABRS (ie, four or more episodes within a 12-month period with resolution of symptoms between episodes) also warrant referral to an otolaryngology specialist. Patients may have an anatomic abnormality contributing to frequent episodes. Recurrent unilateral symptoms increase the suspicion of an anatomic abnormality or other pathology. As described above, noncontrast CT of the sinuses is appropriate for evaluation, and should be done while the patient is symptomatic and prior to initiation of antibiotic therapy Additional otolaryngology evaluation typically includes direct visualization of the middle meatus via endoscopy.
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute rhinosinusitis".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Sinusitis in adults (The Basics)" and "Patient education: What you should know about antibiotics (The Basics)")
●Beyond the Basics topic (see "Patient education: Acute sinusitis (sinus infection) (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Expected illness course – The majority of acute rhinosinusitis (ARS) is viral, and symptoms generally resolve within 7 to 10 days. Acute bacterial rhinosinusitis (ABRS) is more likely in patients with persistent or biphasic symptoms (table 2), but most of those individuals also improve without antibiotic therapy within seven additional days. Complications (extension of infection beyond the sinuses) are very rare but require prompt recognition and management (table 1). (See 'Identify alarm symptoms' above and 'Identify features suggestive of bacterial infection' above.)
●Symptomatic therapy for all patients – We advise initial symptomatic management for all patients with ARS. Over-the-counter analgesics are sufficient for fever and pain. We also suggest saline nasal irrigation for all patients with ARS (Grade 2C), as this may help reduce congestion and nasal secretions with minimal adverse effects. Practice around use of intranasal glucocorticoids varies; the author of the topic uses these for all patients with ARS, while other experts use them more selectively (eg, in patients with concomitant allergic rhinitis or more severe symptoms).(See 'Preferred symptomatic therapy' above.)
We suggest not using systemic glucocorticoids (Grade 2C). Although they may shorten time to symptom improvement, the potential risk of side effects likely outweighs the small benefits. (See 'Systemic glucocorticoids not indicated' above.)
●Continued observation versus antibiotics for those with ABRS – For most patients with ABRS (table 2), we suggest continued observation rather than antibiotics at the time of diagnosis (algorithm 2) (Grade 2C). Exceptions include patients who have immunocompromising conditions, multiple comorbidities, younger age, anatomic abnormalities, or poor or uncertain follow-up; in these patients, we have a low threshold to initiate antibiotics because of the potential for more severe infection.
When observation is selected, we follow up with patients within seven days. Most immunocompetent patients with ABRS improve without antibiotic therapy in this time frame. If patients worsen within seven days or do not improve after seven days, we proceed to antibiotics. (See 'Continued observation for most patients' above.)
●Antibiotic selection and duration – For most patients who require antibiotics, we suggest initial empiric treatment with either amoxicillin or standard-dose amoxicillin-clavulanate (Grade 2C) (algorithm 3 and table 7). For patients with risk factors for resistant Streptococcus pneumoniae (table 6), we suggest high-dose amoxicillin-clavulanate (Grade 2C). All regimens have activity against the most common causes of ABRS, S. pneumoniae and Haemophilus influenze; amoxicillin-clavulanate is active against beta-lactamase-producing H. influenzae and when given at a high dose, against penicillin-nonsusceptible S. pneumoniae. (See 'Choice of agent' above.)
Alternatives for penicillin-allergic patients include doxycycline or a third-generation cephalosporin (with or without clindamycin). We reserve respiratory fluoroquinolones for patients who cannot take other alternatives.
For initial treatment, we suggest a duration of five to seven days rather than longer courses (Grade 2C). (See 'Duration' above.)
●Patients with suboptimal response to initial antibiotic therapy – Failure to improve or recurrence warrant repeat evaluation for complications (with imaging if needed) and confirmation of diagnosis before retreatment (see 'Confirmation of diagnosis' above). Treatment is based on symptom course and severity:
•Mild recurrence of symptoms after initial improvement – We suggest an extended (7 to 10 day) course of the same antibiotic (Grade 2C).
•Moderate to severe recurrence or no improvement within seven days of initial therapy – We suggest retreatment with a different antibiotic regimen than used initially (Grade 2C). We use a 7-to-10-day course for retreatment. The regimen should have broader coverage or be in a different drug class than initial therapy. Options include high-dose amoxicillin-clavulanate, a respiratory fluoroquinolone, or a third-generation cephalosporin plus clindamycin (table 7). (See 'Suboptimal response to antibiotic therapy' above.)
●Indications for otolaryngology referral – Patients who do not improve with ≥2 courses of appropriate antibiotics and those who have frequent infections (≥4 per year) warrant referral to an otolaryngology specialist. Subsequent evaluation typically includes noncontrast CT scan and culture of the sinuses. (See 'Indications for otolaryngology referral' above.)
ACKNOWLEDGMENTS —
The UpToDate editorial staff acknowledges Peter H Hwang, MD, and Anne Getz, MD, who contributed to earlier versions of this topic review.
