Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Microbiology and antibiotic management of chronic rhinosinusitis

Itzhak Brook, MD, MSc
Section Editors
Stephen B Calderwood, MD
Jonathan Corren, MD
Deputy Editor
Allyson Bloom, MD


Chronic rhinosinusitis (CRS) is defined as a complex inflammatory condition involving the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer, despite attempts at medical management. The diagnostic criteria for CRS are discussed separately. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis", section on 'Diagnosis'.)

Factors that may contribute to the development of CRS include exposure to allergens and irritants, defects in mucociliary function, immunodeficiency, and infections with bacteria, viruses, and fungi. The common endpoint is local inflammation and swelling of the sinonasal mucosa and impairment of normal sinus drainage. The recognition that CRS represents a multifactorial inflammatory disorder, rather than simply a persistent bacterial infection, has led to the reexamination of the role of antimicrobials in CRS. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis".)

The medical management of CRS is now focused upon controlling the inflammation that predisposes patients to obstruction, thus minimizing the incidence of infections. Despite this, all forms of CRS are associated with poor sinus drainage and secondary bacterial infections. Most patients require antibiotics to clear infections at the outset of therapy and intermittently thereafter to treat acute exacerbations of CRS. However, the role of these agents beyond these two indications remains an area of investigation. (See "Chronic rhinosinusitis: Management".)

CRS can be divided into three distinct clinical syndromes, since the underlying causes and contributing factors as well as the response to medical or surgical management are different:

CRS with nasal polyposis

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Oct 2017. | This topic last updated: May 16, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Brook I. Aerobic and anaerobic bacterial flora of normal maxillary sinuses. Laryngoscope 1981; 91:372.
  2. Albu S, Florian IS. Bacteriology of normal frontal sinuses. Am J Otolaryngol 2013; 34:327.
  3. Ramakrishnan VR, Hauser LJ, Feazel LM, et al. Sinus microbiota varies among chronic rhinosinusitis phenotypes and predicts surgical outcome. J Allergy Clin Immunol 2015; 136:334.
  4. Aurora R, Chatterjee D, Hentzleman J, et al. Contrasting the microbiomes from healthy volunteers and patients with chronic rhinosinusitis. JAMA Otolaryngol Head Neck Surg 2013; 139:1328.
  5. Danielsen KA, Eskeland O, Fridrich-Aas K, et al. Bacterial biofilms in patients with chronic rhinosinusitis: a confocal scanning laser microscopy study. Rhinology 2014; 52:150.
  6. Sande MA, Gwaltney JM. Acute community-acquired bacterial sinusitis: continuing challenges and current management. Clin Infect Dis 2004; 39 Suppl 3:S151.
  7. Brook I. Acute and chronic bacterial sinusitis. Infect Dis Clin North Am 2007; 21:427.
  8. Bhattacharyya N. The role of infection in chronic rhinosinusitis. Curr Allergy Asthma Rep 2002; 2:500.
  9. Brook I. Bacteriologic features of chronic sinusitis in children. JAMA 1981; 246:967.
  10. Brook I. Bacteriology of chronic maxillary sinusitis in adults. Ann Otol Rhinol Laryngol 1989; 98:426.
  11. Brook I. Bacteriology of acute and chronic frontal sinusitis. Arch Otolaryngol Head Neck Surg 2002; 128:583.
  12. Brook I. Bacteriology of acute and chronic sphenoid sinusitis. Ann Otol Rhinol Laryngol 2002; 111:1002.
  13. Brook I. Bacteriology of acute and chronic ethmoid sinusitis. J Clin Microbiol 2005; 43:3479.
  14. Nord CE. The role of anaerobic bacteria in recurrent episodes of sinusitis and tonsillitis. Clin Infect Dis 1995; 20:1512.
  15. Brook I, Thompson DH, Frazier EH. Microbiology and management of chronic maxillary sinusitis. Arch Otolaryngol Head Neck Surg 1994; 120:1317.
  16. Finegold SM, Flynn MJ, Rose FV, et al. Bacteriologic findings associated with chronic bacterial maxillary sinusitis in adults. Clin Infect Dis 2002; 35:428.
  17. Brook I, Yocum P, Shah K. Aerobic and anaerobic bacteriology of concurrent chronic otitis media with effusion and chronic sinusitis in children. Arch Otolaryngol Head Neck Surg 2000; 126:174.
  18. Erkan M, Ozcan M, Arslan S, et al. Bacteriology of antrum in children with chronic maxillary sinusitis. Scand J Infect Dis 1996; 28:283.
  19. Frederick J, Braude AI. Anaerobic infection of the paranasal sinuses. N Engl J Med 1974; 290:135.
  20. Van Cauwenberge P, Verschraegen G, Van Renterghem L. Bacteriological findings in sinusitis (1963-1975). Scand J Infect Dis Suppl 1976; :72.
  21. Karma P, Jokipii L, Sipilä P, et al. Bacteria in chronic maxillary sinusitis. Arch Otolaryngol 1979; 105:386.
  22. Berg O, Carenfelt C, Kronvall G. Bacteriology of maxillary sinusitis in relation to character of inflammation and prior treatment. Scand J Infect Dis 1988; 20:511.
  23. Erkan M, Aslan T, Ozcan M, Koç N. Bacteriology of antrum in adults with chronic maxillary sinusitis. Laryngoscope 1994; 104:321.
  24. Klossek JM, Dubreuil L, Richet H, et al. Bacteriology of chronic purulent secretions in chronic rhinosinusitis. J Laryngol Otol 1998; 112:1162.
  25. Brook I, Frazier EH, Foote PA. Microbiology of the transition from acute to chronic maxillary sinusitis. J Med Microbiol 1996; 45:372.
  26. Brook I, Yocum P. Immune response to Fusobacterium nucleatum and Prevotella intermedia in patients with chronic maxillary sinusitis. Ann Otol Rhinol Laryngol 1999; 108:293.
  27. Aust R, Drettner B. Oxygen tension in the human maxillary sinus under normal and pathological conditions. Acta Otolaryngol 1974; 78:264.
  28. Carenfelt C, Lundberg C. Purulent and non-purulent maxillary sinus secretions with respect to pO2, pCO2 and pH. Acta Otolaryngol 1977; 84:138.
  29. Brook I, Myhal LA, Dorsey CH. Encapsulation and pilus formation of Bacteroides spp. in normal flora abscesses and blood. J Infect 1992; 25:251.
  30. Brook I. Role of encapsulated anaerobic bacteria in synergistic infections. Crit Rev Microbiol 1987; 14:171.
  31. Doyle PW, Woodham JD. Evaluation of the microbiology of chronic ethmoid sinusitis. J Clin Microbiol 1991; 29:2396.
  32. Shapiro ED, Milmoe GJ, Wald ER, et al. Bacteriology of the maxillary sinuses in patients with cystic fibrosis. J Infect Dis 1982; 146:589.
  33. Nadel DM, Lanza DC, Kennedy DW. Endoscopically guided cultures in chronic sinusitis. Am J Rhinol 1998; 12:233.
  34. Bhattacharyya N, Kepnes LJ. The microbiology of recurrent rhinosinusitis after endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg 1999; 125:1117.
  35. Brook I. Microbiology of acute and chronic maxillary sinusitis associated with an odontogenic origin. Laryngoscope 2005; 115:823.
  36. Decker CF. Sinusitis in the Immunocompromised Host. Curr Infect Dis Rep 1999; 1:27.
  37. Hsu J, Lanza DC, Kennedy DW. Antimicrobial resistance in bacterial chronic sinusitis. Am J Rhinol 1998; 12:243.
  38. Brook I, Frazier EH. Correlation between microbiology and previous sinus surgery in patients with chronic maxillary sinusitis. Ann Otol Rhinol Laryngol 2001; 110:148.
  39. Huang WH, Hung PK. Methicillin-resistant Staphylococcus aureus infections in acute rhinosinusitis. Laryngoscope 2006; 116:288.
  40. Manarey CR, Anand VK, Huang C. Incidence of methicillin-resistant Staphylococcus aureus causing chronic rhinosinusitis. Laryngoscope 2004; 114:939.
  41. Brook I, Foote PA, Hausfeld JN. Increase in the frequency of recovery of meticillin-resistant Staphylococcus aureus in acute and chronic maxillary sinusitis. J Med Microbiol 2008; 57:1015.
  42. Jiang RS, Hsu CY, Jang JW. Bacteriology of the maxillary and ethmoid sinuses in chronic sinusitis. J Laryngol Otol 1998; 112:845.
  43. Brook I, Frazier EH. Bacteriology of chronic maxillary sinusitis associated with nasal polyposis. J Med Microbiol 2005; 54:595.
  44. Kim HJ, Lee K, Yoo JB, et al. Bacteriological findings and antimicrobial susceptibility in chronic sinusitis with nasal polyp. Acta Otolaryngol 2006; 126:489.
  45. Niederfuhr A, Kirsche H, Riechelmann H, Wellinghausen N. The bacteriology of chronic rhinosinusitis with and without nasal polyps. Arch Otolaryngol Head Neck Surg 2009; 135:131.
  46. Brook I, Foote PA, Frazier EH. Microbiology of acute exacerbation of chronic sinusitis. Ann Otol Rhinol Laryngol 2005; 114:573.
  47. Mehra P, Jeong D. Maxillary sinusitis of odontogenic origin. Curr Infect Dis Rep 2008; 10:205.
  48. Saibene AM, Vassena C, Pipolo C, et al. Odontogenic and rhinogenic chronic sinusitis: a modern microbiological comparison. Int Forum Allergy Rhinol 2016; 6:41.
  49. Brook I, Frazier EH, Gher ME Jr. Microbiology of periapical abscesses and associated maxillary sinusitis. J Periodontol 1996; 67:608.
  50. Gillespie MB, O'Malley BW Jr, Francis HW. An approach to fulminant invasive fungal rhinosinusitis in the immunocompromised host. Arch Otolaryngol Head Neck Surg 1998; 124:520.
  51. Jackson RM, Rice DH. Acute bacterial sinusitis and diabetes mellitus. Otolaryngol Head Neck Surg 1987; 97:469.
  52. Godofsky EW, Zinreich J, Armstrong M, et al. Sinusitis in HIV-infected patients: a clinical and radiographic review. Am J Med 1992; 93:163.
  53. Del Borgo C, Del Forno A, Ottaviani F, Fantoni M. Sinusitis in HIV-infected patients. J Chemother 1997; 9:83.
  54. Dunand VA, Hammer SM, Rossi R, et al. Parasitic sinusitis and otitis in patients infected with human immunodeficiency virus: report of five cases and review. Clin Infect Dis 1997; 25:267.
  55. Finegold SM. Anaerobic bacteria in human disease, Academic Press Inc, Orlando, FL 1977.
  56. Brook I. Microbiology of intracranial abscesses and their associated sinusitis. Arch Otolaryngol Head Neck Surg 2005; 131:1017.
  57. Wallwork B, Coman W, Mackay-Sim A, et al. A double-blind, randomized, placebo-controlled trial of macrolide in the treatment of chronic rhinosinusitis. Laryngoscope 2006; 116:189.
  58. Piromchai P, Thanaviratananich S, Laopaiboon M. Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults. Cochrane Database Syst Rev 2011; :CD008233.
  59. Namyslowski G, Misiolek M, Czecior E, et al. Comparison of the efficacy and tolerability of amoxycillin/clavulanic acid 875 mg b.i.d. with cefuroxime 500 mg b.i.d. in the treatment of chronic and acute exacerbation of chronic sinusitis in adults. J Chemother 2002; 14:508.
  60. Legent F, Bordure P, Beauvillain C, Berche P. A double-blind comparison of ciprofloxacin and amoxycillin/clavulanic acid in the treatment of chronic sinusitis. Chemotherapy 1994; 40 Suppl 1:8.
  61. Husfeldt P, Egede F, Nielsen PB. Antibiotic treatment of sinusitis in general practice. A double-blind study comparing ofloxacin and erythromycin. Eur Arch Otorhinolaryngol 1993; 250 Suppl 1:S23.
  62. Dubin MG, Kuhn FA, Melroy CT. Radiographic resolution of chronic rhinosinusitis without polyposis after 6 weeks vs 3 weeks of oral antibiotics. Ann Allergy Asthma Immunol 2007; 98:32.
  63. Brook I, Yocum P. Antimicrobial management of chronic sinusitis in children. J Laryngol Otol 1995; 109:1159.
  64. Ragab SM, Lund VJ, Scadding G. Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomised, controlled trial. Laryngoscope 2004; 114:923.
  65. Brook I. The role of beta-lactamase-producing bacteria in the persistence of streptococcal tonsillar infection. Rev Infect Dis 1984; 6:601.
  66. Sacks PL 4th, Harvey RJ, Rimmer J, et al. Antifungal therapy in the treatment of chronic rhinosinusitis: a meta-analysis. Am J Rhinol Allergy 2012; 26:141.
  67. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015; 152:S1.
  68. Brook I. Role of methicillin-resistant Staphylococcus aureus in head and neck infections. J Laryngol Otol 2009; 123:1301.
  69. Brook I. Beta-lactamase-producing bacteria in head and neck infection. Laryngoscope 1988; 98:428.
  70. Rudmik L, Soler ZM. Medical Therapies for Adult Chronic Sinusitis: A Systematic Review. JAMA 2015; 314:926.
  71. Lee JT, Chiu AG. Topical anti-infective sinonasal irrigations: update and literature review. Am J Rhinol Allergy 2014; 28:29.
  72. Jervis-Bardy J, Boase S, Psaltis A, et al. A randomized trial of mupirocin sinonasal rinses versus saline in surgically recalcitrant staphylococcal chronic rhinosinusitis. Laryngoscope 2012; 122:2148.
  73. Jervis-Bardy J, Wormald PJ. Microbiological outcomes following mupirocin nasal washes for symptomatic, Staphylococcus aureus-positive chronic rhinosinusitis following endoscopic sinus surgery. Int Forum Allergy Rhinol 2012; 2:111.
  74. Carr TF, Hill JL, Chiu A, Chang EH. Alteration in Bacterial Culture After Treatment With Topical Mupirocin for Recalcitrant Chronic Rhinosinusitis. JAMA Otolaryngol Head Neck Surg 2016; 142:138.
  75. Whatley WS, Chandra RK, MacDonald CB. Systemic absorption of gentamicin nasal irrigations. Am J Rhinol 2006; 20:251.
  76. Cheng AG, Johnston PR, Luz J, et al. Sensorineural hearing loss in patients with cystic fibrosis. Otolaryngol Head Neck Surg 2009; 141:86.
  77. Kennedy JL, Borish L. Chronic rhinosinusitis and antibiotics: the good, the bad, and the ugly. Am J Rhinol Allergy 2013; 27:467.
  78. Suman JD, Laube BL, Dalby R. Nasal nebulizers versus aqueous nasal spray pumps: A comparison of deposition patterns in human volunteers. In: Respiratory Drug Delivery VI, Dalby RN, Byron PR, Farr SJ (Eds), Interpharm Press, Buffalo Grove, IL 1998. p.211.
  79. Durand M, Rusch P, Granjon D, et al. Preliminary study of the deposition of aerosol in the maxillary sinuses using a plastinated model. J Aerosol Med 2001; 14:83.
  80. Lim M, Citardi MJ, Leong JL. Topical antimicrobials in the management of chronic rhinosinusitis: a systematic review. Am J Rhinol 2008; 22:381.
  81. Leonard DW, Bolger WE. Topical antibiotic therapy for recalcitrant sinusitis. Laryngoscope 1999; 109:668.
  82. Goh YH, Goode RL. Current status of topical nasal antimicrobial agents. Laryngoscope 2000; 110:875.
  83. Scheinberg PA, Otsuji A. Nebulized antibiotics for the treatment of acute exacerbations of chronic rhinosinusitis. Ear Nose Throat J 2002; 81:648.
  84. Vaughan WC, Carvalho G. Use of nebulized antibiotics for acute infections in chronic sinusitis. Otolaryngol Head Neck Surg 2002; 127:558.