Antibiotic prescribing for acute rhinosinusitis
WHEN TO TREAT ― Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after 7 days. Only about 2% of cases are complicated with bacterial infection (however these can be hard to distinguish). Duration of symptoms of acute sinusitis is usually 2-3 weeks. Use adequate analgesia. For patients with symptoms of less than 10 days, do not offer an antibiotic prescription. Give advice on course of acute sinusitis (2-3 weeks), managing symptoms with self-care and seeking help if symptoms deteriorate rapidly or significantly, do not improve after 3 weeks or they become systemically unwell. For patients with symptoms of around 10 days or more with no improvement, consider high dose nasal corticosteroid for 14 days in adults and children over 12 years (may improve symptoms but not affect length of course of illness). Caution for side effects especially in patients receiving other corticosteroids.
ANTIBIOTICS ― Consider No or delayed antibiotic prescription (with advice as to when to use the prescription and evidence that antibiotics make little difference to symptom course length and can cause side effects) if several of: purulent nasal discharge, severe localized unilateral pain, fever, marked deterioration after initial milder phase. Consider an immediate antibiotic prescription only if it is not appropriate to admit the person and they are systemically unwell, or at high risk of complications because of a pre-existing comorbidity. Recommend measures to relieve symptoms, such as analgesia for pain or fever, an intranasal decongestant, and irrigation of the nose with normal saline solution, application of warm face packs, drinking adequate fluids, and rest.
WHEN TO INVESTIGATE
Investigations are not required in primary care because nasal swabs for culture have a poor diagnostic yield and are frequently contaminated (or bacteria found are commensal). Acute sinusitis usually follows a common cold, and is defined as an increase in symptoms after 5 days, or persistence of symptoms beyond 10 days, but less than 12 weeks.
ANTIBIOTIC PRESCRIBING
EMPIRIC ANTIBIOTIC THERAPY ― Beta-lactam such as amoxicillin clavulanate (Co-Amoxiclav) is preferred first-line treatment. Dosing options include 500 mg/125 mg orally 3 times daily or 875 mg/125 mg orally twice daily. For those at risk of antibiotic resistance (such as > 65 years old, immunocompromised status, or recent hospitalization) use 2,000 mg/125 mg orally twice daily. If beta-lactam allergy, use 1 of the following...- Doxycycline 100 mg orally twice daily or 200 mg orally once daily.
- Levofloxacin 500 mg orally once daily.
- Moxifloxacin 400 mg orally once daily.
- Ceftriaxone 1-2 g IV every 12-24 hours.
- Cefotaxime 2 g IV every 4-6 hours.
- Levofloxacin 500 mg orally or IV once daily.
- Moxifloxacin 400 mg orally or IV once daily.
REFERENCES
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Documents | Sinusitis (acute): antimicrobial prescribing | Guidance | NICE. [online] Available at: https://www.nice.org.uk/guidance/NG79/history
Chow, A.W., Benninger, M.S., Brook, I., Brozek, J.L., Goldstein, E.J.C., Hicks, L.A., Pankey, G.A., Seleznick, M., Volturo, G., Wald, E.R. and File, T.M. (2012). Executive Summary: IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clinical Infectious Diseases, 54(8), pp.1041–1045. Available at: https://academic.oup.com/cid/article/54/8/1041/364141
Rosenfeld, R.M., Piccirillo, J.F., Chandrasekhar, S.S., Brook, I., Ashok Kumar, K., Kramper, M., Orlandi, R.R., Palmer, J.N., Patel, Z.M., Peters, A., Walsh, S.A. and Corrigan, M.D. (2015). Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngology–Head and Neck Surgery, [online] 152(2_suppl), pp.S1–S39. Available at: https://journals.sagepub.com/doi/10.1177/0194599815572097
