This protocol applies to patients with uncomplicated acute bacterial rhinosinusitis (ABRS) and no penicillin allergy whose symptoms have not improved as expected on a first-line amoxicillin-based regimen.
ABRS is diagnosed when purulent nasal drainage, accompanied by nasal obstruction and/or facial pain-pressure-fullness, persists without improvement for at least 10 days — or worsens within 10 days after initial improvement (double worsening). The infection is uncomplicated: there is no neurologic, ophthalmologic, or soft-tissue extension beyond the paranasal sinuses and nasal cavity.
The patient has already received first-line amoxicillin (with or without clavulanate). Signs and symptoms of ABRS should generally improve within 3 to 5 days after initiating antibiotic therapy. When that improvement does not occur, escalation to the next antibiotic step is indicated.
DOI: 10.1002/ohn.1344
A clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis (purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both) persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening).
Uncomplicated rhinosinusitis is defined as rhinosinusitis without clinically evident extension of inflammation outside the paranasal sinuses and nasal cavity at the time of diagnosis (e.g., no neurologic, ophthalmologic, or soft tissue involvement).
If ABRS is confirmed, the clinician should change the antibiotic.
Optimal therapy of multi-drug resistant S. pneumoniae and beta-lactamase-producing H. influenzae and M. catarrhalis, would include high-dose amoxicillin-clavulanate (4 g per day amoxicillin equivalent) or a respiratory fluoroquinolone (ie, levofloxacin, moxifloxacin,) if no alternative agents are available.
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