Acute Bacterial Rhinosinusitis in Children and Adults

Publication Date: April 15, 2012

Diagnosis

The Infectious Diseases Society of America (IDSA) recommends any one of the following clinical presentations for identifying patients with acute bacterial versus viral rhinosinusitis:
Onset with “persistent” symptoms or signs compatible with acute rhinosinusitis, lasting for ≥10 days without any evidence of clinical improvement. (SR, )
(LM)
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Onset with “severe” symptoms or signs of high fever (≥39ºC or 102ºF) and purulent nasal discharge or facial pain lasting for at least 3-4 consecutive days at the beginning of illness. (SR, )
(LM)
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Onset with “worsening” symptoms or signs characterized by the new onset of fever, headache or increase in nasal discharge following a typical viral URI that lasted 5-6 days and were initially improving (“double-sickening”). (SR, )
(LM)
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Initial Treatment

The IDSA recommends empiric antimicrobial therapy be initiated as soon as the clinical diagnosis of ABRS is established as defined above. (SR, M)
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The IDSA recommends amoxicillin-clavulanate rather than amoxicillin alone as empiric antimicrobial therapy for ABRS in children (SR, M)
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The IDSA recommends amoxicillin-clavulanate rather than amoxicillin alone as empiric antimicrobial therapy for ABRS in adults (WR, L)
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The IDSA recommends “high-dose” amoxicillin-clavulanate for:
  • children and adults with ABRS from geographic regions with high endemic rates (≥ 10%) of invasive penicillin-nonsusceptible (PNS) S. pneumoniae
  • those with severe infection (eg, evidence of systemic toxicity with fever ≥ 39ºC [102ºF] and threat of suppurative complications)
  • those at risk of antibiotic resistance.
    • Attendance at day-care
    • Age < 2 or > 65 years
    • Recent hospitalization
    • Antibiotic use within the past month
    • Those who are immunocompromised.
(WR, M)
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The IDSA recommends a β-lactam agent (amoxicillin-clavulanate) rather than a respiratory fluoroquinolone for initial empiric antimicrobial therapy of ABRS. (WR, M)
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Macrolides (clarithromycin and azithromycin) are NOT recommended for empiric therapy due to high rates of resistance among S. pneumoniae (~30%). (SR, M)
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Trimethoprim/sulfamethoxazole (TMP/SMX) is NOT recommended for empirical therapy due to high rates of resistance among both S. pneumoniae and H. influenzae (~30%-40%). (SR, M)
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Doxycycline may be used as an alternative regimen to amoxicillin-clavulanate for initial empiric antimicrobial therapy of ABRS in adults since it remains highly active against respiratory pathogens and has excellent pharmacokinetic/pharmacodynamic properties. (WR, L)
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Second and third generation oral cephalosporins are no longer recommended for empiric monotherapy of ABRS due to variable rates of resistance among S. pneumoniae. Combination therapy with a third generation oral cephalosporin (cefixime or cefpodoxime) plus clindamycin may be used as second line therapy for children with non–type I penicillin allergy or from geographic regions with high endemic rates of PNSS. pneumoniae. (WR, M)
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The IDSA recommends either doxycycline (not suitable for children) or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) as alternative agents for empiric antimicrobial therapy in adults who are allergic to penicillin. (SR, M)
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The IDSA recommends levofloxacin for children with a history of type I hypersensitivity to penicillin. Combination therapy with clindamycin plus a third generation oral cephalosporin (cefixime or cefpodoxime) is recommended in children with a history of non–type I hypersensitivity to penicillin. (WR, L)
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Although S. aureus (including methicillin-resistant S. aureus [MRSA]) is a potential pathogen in ABRS, based on current data routine antimicrobial coverage for S. aureus or MRSA during initial empiric therapy of ABRS is NOT recommended. (SR, M)
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Duration of Treatment

The recommended duration of therapy for uncomplicated ABRS in adults is 5-7 days. (WR)
(LM)
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In children with ABRS, the IDSA still recommends a longer treatment duration of 10-14 days. (WR)
(LM)
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Adjunctive Treatment

The IDSA recommends intranasal saline irrigations with either physiologic or hypertonic saline as an adjunctive treatment in adults with ABRS. (WR)
(LM)
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The IDSA recommends intranasal corticosteroids as an adjunct to antibiotics in the empiric treatment of ABRS, primarily in those with a history of allergic rhinitis. (WR, M)
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Neither topical nor oral decongestants and/or antihistamines are recommended as adjunctive treatment in patients with ABRS. (SR)
(LM)
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Secondary Treatment

The IDSA recommends an alternative management strategy if symptoms worsen after 48-72 hours of initial empiric antimicrobial therapy or fail to improve despite 3-5 days of initial empiric antimicrobial therapy. (SR, M)
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Evaluated patients who clinically worsen despite 72 hours, or fail to improve after 3-5 days, of empiric antimicrobial therapy with a first-line agent for the possibility of resistant pathogens, a noninfectious etiology, structural abnormality or other causes for treatment failure. (SR, L)
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The IDSA recommends that cultures be obtained by direct sinus aspiration rather than by nasopharyngeal swabs in patients with suspected sinus infection who have failed to respond to empiric antimicrobial therapy. (SR, M)
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Consider endoscopically guided cultures of the middle meatus as an alternative in adults, but their reliability in children has not been established (WR, M)
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Nasopharyngeal cultures are unreliable and are NOT recommended for the microbiologic diagnosis of ABRS. (SR, H)
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In patients with ABRS suspected to have suppurative complications, the IDSA recommends axial and coronal views of contrast-enhanced computerized tomography (CT) rather than magnetic resonance imaging (MRI) to localize the infection and to guide further treatment (WR, L)
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Recommendation Grading

Disclaimer

Overview

Title

Acute Bacterial Rhinosinusitis in Children and Adults

Authoring Organization

Publication Month/Year

April 15, 2012

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D001424 - Bacterial Infections

Keywords

rhinosinusitis, Acute bacterial rhinosinusitis, ABRS

Source Citation

Anthony W. Chow, Michael S. Benninger, Itzhak Brook, Jan L. Brozek, Ellie J. C. Goldstein, Lauri A. Hicks, George A. Pankey, Mitchel Seleznick, Gregory Volturo, Ellen R. Wald, Thomas M. File, Jr, IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults, Clinical Infectious Diseases, Volume 54, Issue 8, 15 April 2012, Pages e72–e112, https://doi.org/10.1093/cid/cis370