The first-ever recommendations for the diagnosis and management of acute bacterial rhinosinusitis (ABRS) infections were published by the Infectious Diseases Society of America. Posted online at the end of March, they will appear in the April 15, 2012 issue of Clinical Infectious Diseases.

Rhinosinusitis is the 5th leading indication for antimicrobial prescriptions by doctors in a practice. Due to a lack of existing clinical criteria to accurately differentiate bacterial from viral acute rhinosinusitis, excessive and inappropriate antibiotic prescriptions occur. Clinicians are forced to rely on clinical presentations to distinguish bacterial from viral rhinosinusitis. The new ABRS guidelines suggest that the infection is probably bacterial if any of the following are present:

Persistent symptoms or signs of acute rhinosinusitis last for 10 days or more.
Severe symptoms or signs of high fever (102°F) and purulent nasal discharge or facial pain lasting for at least 3-4 consecutive days at the beginning of an illness
Worsening symptoms or signs characterized by new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection that lasted 5-6 days and initially improved (“double-sickening”)

First-line therapy:

Once a clinical diagnosis of ABRS is established, it is recommended that empiric antimicrobial therapy be initiated immediately with amoxicillin-clavulanate (rather than amoxicillin alone) for both adults and children.

High-dose (2 g orally twice daily or 90 mg/kg/day orally twice daily) amoxicillin-clavulanate is recommended for children and adults with ABRS from geographic regions with high endemic rates of invasive penicillin-nonsusceptible S. pneumoniae, those with severe infection, attendance at daycare, age <2 or >65 years, recent hospitalization, antibiotic use within the past month, or who are immunocompromised.

Second-line therapy:

Doxycycline may be used as an alternate regimen to amoxicillin-clavulanate in adults.
Macrolides (ie, clarithromycin and azithromycin), trimethoprim-sulfamethoxazole (TMP/SMX), and second-and third-generation oral cephalosporins are no longer recommended due to variable rates of resistance among S. pneumoniae.
Combination therapy with a third-generation oral cephalosporin (ie, cefixime or cefpodoxime) plus clindamycin may be used as second-line therapy for children with non–type I penicillin allergy or from geographic regions with high endemic rates of penicillin-nonsusceptible S. pneumonia
Doxycycline or a respiratory fluoroquinolone is recommended as an alternative agent for empiric antimicrobial therapy in adults who are allergic to penicillin.
Levofloxacin is recommended for children with a history of type I hypersensitivity to penicillin; combination therapy with clindamycin plus a third-generation oral cephalosporin (cefixime or cefpodoxime) is recommended in children with a history of non–type I hypersensitivity to penicillin (weak, low).

The guidelines recommend 5 to 7 days of therapy for uncomplicated ABRS and 10 to 14 days for children.  Adjunct therapy such as intranasal saline irrigations and intranasal corticosteroids are recommended. Topical and oral decongestants and antihistamines are not recommended as adjunct therapy.