Empiric antimicrobial therapy for outpatient treatment of uncomplicated acute bacterial rhinosinusitis (ABRS) in immunocompetent adults

ABRS: acute bacterial rhinosinusitis.

* Indications for antibiotic therapy include lack of adequate follow-up, worsening symptoms during observation, and symptoms unchanged after 7 days of observation. Refer to the UpToDate topic on treatment of uncomplicated acute sinusitis and rhinosinusitis in adults for details.

¶ Refer to the UpToDate topics on penicillin allergy and cephalosporin allergy.

Δ Risk factors for resistance or poor outcome include:

• Living in geographic regions with rates of penicillin-nonsusceptible Streptococcus pneumoniae exceeding 10%
• Age ≥65 years
• Hospitalization in the last 5 days
• Antibiotic use in the previous month
• Immunocompromised
• Multiple comorbidities (eg, diabetes or chronic cardiac, hepatic, or renal disease)
• Severe infection (eg, evidence of systemic toxicity with temperature of ≥102°F)

◊ Selection among these agents depends on patient allergies (as above), comorbidities, potential adverse drug effects, likelihood of patient adherence, and other patient values and preferences.

§ A respiratory fluoroquinolone (eg, levofloxacin 750 mg or 500 mg orally daily or moxifloxacin 400 mg orally daily) is an additional option for initial treatment but should be reserved for those who cannot tolerate other options as the serious adverse effects associated with fluoroquinolones generally outweigh the benefits for patients with acute rhinosinusitis.

¥ Doxycycline and fluoroquinolones should be avoided in pregnancy.

‡ The addition of clindamycin provides improved coverage for beta-lactam-resistant S. pneumoniae but carries increased risk of adverse effects (eg, Clostridioides [formerly Clostridium] difficile infection).

† The diagnosis of ABRS can be confirmed clinically. In patients in whom there are concerns for complications, imaging should be obtained. In other patients in whom symptoms are not completely consistent with ABRS, imaging is reasonable to rule out sinusitis and/or evaluation for alternative diagnosis.

** Signs and symptoms of complications include toxic appearance, altered mental status, neurologic deficits, and/or evidence of extension of infection into the surrounding skin, soft tissue, or bone. Refer to the UpToDate topics on the diagnosis of acute rhinosinusitis, deep neck space infections, and orbital cellulitis for additional detail.

¶¶ For patients who received a respiratory fluoroquinolone as initial therapy, antimicrobial resistance is unlikely to be the cause of treatment failure. We often pursue evaluation in such patients in place of or in addition to prescribing a second course of antibiotics.