Acute Bacterial Rhinosinusitis: Physician Information Sheet (Adults)

Principles of appropriate antibiotic use for acute rhinosinusitis apply to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in otherwise healthy adults.

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Sinus inflammation is often viral and usually resolves without antibiotics.

Background

• Respiratory viruses typically cause inflammation of the nasalmucosa and maxillary sinuses.
• Most cases of acute rhinosinusitis are due to uncomplicated viral infections.

Diagnosis

• Most rhinovirus colds last 7 to 11 days (J Clin Microbiol 1997; 35:2864; JAMA 1967; 202:158).
• Bacterial rhinosinusitis may be present if symptoms have been present >7 days and there is localization to the maxillary sinus.

Signs/Symptoms of Acute Maxillary Sinusitis

(BMJ 1995;311:233)

 

	Present (N=92)	Absent (N=82)	Odds Ratio
Fever	89%	79%	2.1
Unilateral maxillary pain	51%	38%	1.9
Maxillary toothache	66%	51%	1.9
Unilateral maxillary sinus tenderness	49%	32%	2.5

• Generalized facial pain or tenderness, postnasal drainage, headache, and cough do not increase the predictive value of maxillary sinus symptoms.
• Patients may rarely present with severe symptoms of bacterial rhinosinusitis less than 7 days duration (acute focal sinusitis). Consider immediate referral to an otolaryngologist for evaluation and drainage.
• Sinus radiography is not recommended for routine evaluation of acute, uncomplicated bacterial rhinosinusitis.
  • Opacification and air-fluid level have sensitivity of ~ 73% and specificity of 80% (J Clin Epidemiol 2000;53:852).
  • Mucosal abnormalities are common in patients with viral infections (J Allergy Clin Immunol 1998;102:403).

Treatment

• Most patients with acute bacterial rhinosinusitis improve without antibiotic treatment.
  • About 81% of antibiotic treated patients and 66% of controls are improved at 10-14 days (absolute benefit of 15%).
• Patients with mild symptoms should not receive antibiotics, but symptomatic treatment may be helpful.
  • Topical and oral decongestants may reduce nasal symptoms.
  • Most randomized trials of symptomatic therapies have been inconclusive. Patients with moderate or severe symptoms may benefit from antibiotics. Use a narrow spectrum agent that covers S. pneumoniae and H. influenzae.
  • Amoxicillin remains an appropriate choice for uncomplicated infections.
  • Consider second line agent if no improvement or worsening after 72 hours.

Tips to Reduce Antibiotic Use

• Tell patients that antibiotic use increases the risk of an antibiotic resistant infection.
• Identify and validate patient concerns.
• Recommend specific symptomatic therapy.
• Spend time answering questions and offer a contingency plan if symptoms worsen.
• Provide patient education materials on antibiotic resistance.
• REMEMBER: Effective communication is more important than an antibiotic for patient satisfaction.
• See www.cdc.gov/ drugresistance/ community or contact your local health department for more information and patient education materials.

Key Reference

Cooper RJ et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Annals of Internal Medicine 2001;134(6):509-17