Acute rhinosinusitis: When to prescribe an antibiotic
Yes, the majority of antibiotics prescribed for acute rhinosinusitis are unnecessary, but when should you prescribe one and which one(s) should you use?
PRACTICE RECOMMENDATIONS
› Reserve antibiotics for patients who meet diagnostic criteria for acute bacterial rhinosinusitis (ABRS). Patients must have purulent nasal drainage that is accompanied by either nasal obstruction or facial pain/pressure/fullness and EITHER symptoms that persist without improvement for at least 10 days OR symptoms that worsen within 10 days of initial improvement (“double sickening”). A
› Offer watchful waiting and delay antibiotics for up to 7 days after diagnosing ABRS in a patient if adequate access to follow-up is available; otherwise, treat with amoxicillin (with or without clavulanate) for 5 to 10 days. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Diagnosis and management of pediatric patients
Diagnosis of ABRS in children is defined as an acute upper respiratory infection (URI) accompanied by persistent nasal discharge, daytime cough for ≥ 10 days without improvement, an episode of “double sickening,” or severe onset with a temperature ≥ 102°F and purulent nasal discharge for 3 days.15
Initial presentations of viral URIs and ABRS are almost identical; thus, persistence of symptoms is key to diagnosis.6 Nasal discharge tends to appear several days after initial symptoms manifest for viral infections including influenza. In children < 5 years of age, the most common complication involves the orbit.15 Orbital complications generally manifest with eye pain and/or periorbital swelling and may be accompanied by proptosis or decreased functioning of extraocular musculature. The differential diagnosis for orbital complications includes cavernous sinus thrombosis, orbital cellulitis/abscess, subperiosteal abscess, and inflammatory edema.27,28 Intracranial complications are also possible with severe ABRS.12
Radiology studies are not recommended for the initial diagnosis of ABRS in children, as again, imaging does not differentiate between viral and bacterial etiologies. However, in children with complications such as orbital or cerebral involvement, a contrast-enhanced CT scan of the paranasal sinuses is indicated.15
Antibiotic therapy is indicated in children with a diagnosis of severe ABRS or in cases of “double sickening.” Clinicians may consider watchful waiting for 3 additional days before initiating antibiotics in patients meeting criteria for ABRS.Amoxicillin with or without clavulanate is the antibiotic of choice.15
For penicillin-allergic children without a history of anaphylactoid reaction, treatment with cefpodoxime, cefdinir, or cefuroxime is appropriate. For children with a history of anaphylaxis, treatment with a combination of clindamycin (or linezolid) and cefixime is indicated. Alternatively, a fluoroquinolone such as levofloxacin may be used, but adverse effects and emerging resistance limit its use.15
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