Rhinosinusitis is the mucosal inflammation of the nose and paranasal sinuses caused by bacteria lasting >10 days for up to 4 weeks, symptoms resolve completely and may either be persistent or severe.
It is often preceded by a viral upper respiratory tract infection.
Signs & symptoms are nonspecific and it is typically difficult to differentiate from viral upper respiratory tract infection.
Streptococcus pneumoniae is the most common cause followed by nontypeable Haemophilus influenzae.

Principles of Therapy

Symptomatic Therapy

  • Symptomatic treatment is the preferred initial management in patients w/ mild symptoms
  • Routine use of systemic decongestants & mucolytic agents is not recommended due to limited & controversial data

Antibiotic Therapy 

  • Goals of therapy:
    • Rapid recovery
    • Prevent severe complications (eg meningitis, brain abscess)
    • Avoid chronic sinus disease
  • Consider local pathogen distribution & rates of antibacterial resistance in treatment selection
  • Recommended duration of antimicrobial treatment is 10-14 days to minimize development of bacterial resistance
    • Alternative is to continue treatment 7 days after resolution of symptoms


Symptomatic Therapy

Analgesics & Antipyretics

  • Analgesics are useful in controlling pain
  • Antipyretics may be used to relieve fever
  • Avoid Aspirin in patients ≤16 years of age because of the risk of Reye’s Syndrome

Intranasal Corticosteroids

  • Several studies show that intranasal corticosteroids may be an effective add-on to antimicrobials especially if given in the early course of the disease
  • Reduce cough & nasal discharge
  • Reduce the swelling around the sinus ostia that may hasten the resolution of symptoms

Topical Decongestants

  • May relieve nasal congestion in appropriate concentrations
  • Should be limited to <10 days to avoid rhinitis medicamentosa

Antibiotic Therapy

Mild & No Antibiotic of <90 Days

Amoxicillin (Usual or High-dose)

  • 1st-line drug of choice in uncomplicated acute bacterial rhinosinusitis (ABRS)
  • High-dose Amoxicillin (90 mg/kg/day) is considered in the following patients:
    • At risk of treatment failure due to resistant pathogens
    • Need for better H influenzae coverage
    • In areas w/ a high prevalence of penicillin-resistant S pneumoniae or drug-resistant S pneumoniae
    • W/ moderate disease

Amoxicillin/Clavulanic acid w/ or w/o High-dose Amoxicillin

  • Recommended in patients who have failed high-dose Amoxicillin or in suspected cases of beta-lactamase producing strains of H influenzae & M catarrhalis


  • Effective against beta-lactamase producing bacterial strains (eg S pneumoniae, H influenzae & M catarrhalis)
  • Indicated for treatment of infections resistant to single therapy w/ beta-lactam or Cephalosporins

Cephalosporins (2nd & 3rd Generation)

  • 2nd-line of therapy for ABRS
  • Considered 1st-line agents especially for patients w/ ABRS that have non-type 1 allergy to Penicillin
  • Cefuroxime, Cefpodoxime & Cefdinir are recommended because of their effectiveness against Penicillin-resistant S pneumoniae, H influenzae & M catarrhalis


  • These agents may be considered alternative agents in patients who have type 1 allergy to Penicillin
  • Azithromycin is highly efficacious against H influenzae & Moraxella sp
  • Clarithromycin has slightly greater activity against S pneumoniae


  • Alternative agent for Penicillin-allergic patient infected w/ Penicillin-resistant S pneumoniae

Moderate to Severe Acute Bacterial Rhinosinusitis (ABRS) or Antibiotic Use of <90 Days

Amoxicillin/Clavulanic acid

  • 1st-line agent for patients who have failed Amoxicillin therapy or in those w/ risk of resistant organisms
  • Therapy should be initiated w/ high-dose Amoxicillin/Clavulanic acid (80-90 mg/kg/day based on Amoxicillin,w/ 6.4mg/kg/day of Clavulanic acid in 2 divided doses)
    • High-dose Amoxicillin will increase the coverage against S pneumoniae (all intermediate resistant & most highly resistant strains)
    • Clavulanic acid amount is sufficient to inhibit all beta-lactamase producing H influenzae & M catarrhalis


  • Effective against beta-lactamase producing bacterial strains
  • Indicated for treatment of infections resistant to single therapy w/ beta-lactam or Cephalosporins

Cephalosporins (2nd & 3rd Generations)

  • Considered an alternative therapy for ABRS
  • Cefuroxime, Cefpodoxime & Cefdinir are recommended


  • Recommended as an alternative agent for patients who did not improve w/ 2nd-line agents
  • A single dose of Ceftriaxone (50 mg/kg/day) can be administered through intramuscular (IM)/intravenous (IV) in patients w/ symptoms ofvomiting precluding intake of oral antibiotics, then shifted to oral antibiotics after 24 hours of improvement to complete the treatment

Combination Therapy

  • Combination therapy w/ adequate Gram +ve & -ve coverage may be considered in patients at risk of resistant organisms or in whom 2nd-line therapy has failed
  • Combination therapy regimens:
    • High-dose Amoxicillin or Clindamycin + Cefi xime or Ceftibuten
    • High-dose Amoxicillin or Clindamycin + Rifampicin

Clindamycin + Rifampicin

  • Recommended in patients w/ history of beta-lactam allergy
  • Clindamycin is the most active agent against S pneumoniae; no coverage against M catarrhalis & H influenzae
  • Rifampicin is active against S pneumoniae, H influenzae & M catarrhalis
    • Not recommended for prolonged use (>10-14 days) & as monotherapy due to possible development of drugresistance
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