Acute rhinosinusitis
ICD-10 J01 · ICD-11 CA01

Uncomplicated Acute Bacterial Rhinosinusitis with Confirmed Type-1 Penicillin Hypersensitivity — When Doxycycline Has Not Worked

Clinical Scenario

Uncomplicated acute bacterial rhinosinusitis (ABRS) in a patient with confirmed type-1 penicillin hypersensitivity. Penicillin-based agents are contraindicated, necessitating an alternative empiric antimicrobial strategy from the outset.

Previous Line Failure

Doxycycline — the recommended alternative empiric antimicrobial for confirmed type-1 penicillin hypersensitivity — did not achieve the expected outcome. Signs and symptoms of ABRS should generally improve within 3 to 5 days of initiating antibiotic therapy. When that improvement has not been observed, escalation to this next-line protocol is indicated.

Next-Line Approach

This protocol involves a respiratory fluoroquinolone — a reserve antimicrobial class designated for use only when no other treatment alternatives remain available.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1002/ohn.1344

  1. 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).
  2. When type-1 penicillin hypersensitivity is confirmed, doxycycline (100 mg or 200 mg PO bid) is recommended as an alternative agent for empiric antimicrobial therapy.
  3. Respiratory fluoroquinolone (levofloxacin 500 mg or 750 mg PO od or moxifloxacin 400 mg PO od) is another alternative, but this antibiotic regimen should be reserved for those who have no alternative treatment options for reasons noted above.
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