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Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment
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Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2016. | This topic last updated: Mar 18, 2016.

INTRODUCTION — Acute rhinosinusitis (ARS) is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses (figure 1) lasting less than four weeks. The term "rhinosinusitis" is preferred to "sinusitis" since inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa [1].

The most common etiology of ARS is a viral infection. The clinical manifestations and diagnosis of ARS are discussed separately. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis".)

Treatment for acute viral rhinosinusitis (AVRS) focuses on symptomatic management as it typically resolves within 7 to 10 days. Bacterial infection occurs in only 0.5 to 2.0 percent of episodes of ARS [2]. Acute bacterial rhinosinusitis (ABRS) may also be a self-limited disease. Patients may be treated symptomatically and observed or treated with antibiotics. Rarely, patients with ABRS develop serious complications.

This topic will address the treatment of uncomplicated ARS. The treatment of complications of ABRS are discussed in the appropriate topics. As examples:

Orbital cellulitis (see "Orbital cellulitis")

Preseptal (periorbital) cellulitis (see "Preseptal cellulitis")

Intracranial abscess (see "Treatment and prognosis of bacterial brain abscess")

Meningitis (see "Initial therapy and prognosis of bacterial meningitis in adults")

The treatment of nosocomial bacterial sinusitis and acute invasive fungal sinusitis are also discussed separately. (See "Endotracheal tube management and complications", section on 'Treatment' and "Fungal rhinosinusitis", section on 'Treatment'.)

ACUTE VIRAL RHINOSINUSITIS — Patients with acute viral rhinosinusitis (AVRS) should be managed with supportive care [3]. There are no treatments to shorten the clinical course of the disease. (See 'Symptomatic therapies' below.)

Natural history — AVRS may not completely resolve within 10 days but is expected to improve. Patients who fail to improve after ≥10 days of symptomatic management are more likely to have acute bacterial rhinosinusitis (ABRS) and should be managed as ABRS patients. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Acute bacterial rhinosinusitis' and 'Acute bacterial rhinosinusitis' below.)

Symptomatic therapies — Symptomatic management of acute rhinosinusitis (ARS), both viral and bacterial in etiology, aims to relieve symptoms of nasal obstruction and rhinorrhea, as well as the systemic symptoms associated with fever and fatigue. When needed, we suggest over-the-counter (OTC) analgesics and antipyretics, saline irrigation, and intranasal glucocorticoids for symptomatic management in patients with ARS.

Analgesics and antipyretics — OTC analgesics and antipyretics such as nonsteroidal antiinflammatories and acetaminophen can be used for pain and fever relief as needed [4,5].

Saline irrigation — Mechanical irrigation with buffered, physiologic, or hypertonic saline may reduce the need for pain medication and improve overall patient comfort, particularly in patients with frequent sinus infections. The evidence supporting the use of saline irrigation is limited, but indicates possible benefits for symptom relief with minor adverse effects, such as nasal burning and irritation [6]. It is important that irrigants be prepared from sterile or bottled water, as there have been reports of amebic encephalitis due to tap water rinses [7]. Instructions for preparing a rinse solution are shown in a table (table 1).

Intranasal glucocorticoids — Studies have shown small symptomatic benefits and minimal adverse effects with short-term use of intranasal glucocorticoids for patients with both viral and bacterial ARS [4,5]. Intranasal glucocorticoids are likely to be most beneficial for patients with underlying allergic rhinitis. The theoretic mechanism of action is a decrease in mucosal inflammation that allows improved sinus drainage.

A meta-analysis of three studies, involving patients with ARS diagnosed by symptoms and confirmed by radiologic or endoscopic studies, found that use of intranasal steroids increased the rate of symptom response compared with placebo (RR 1.11, 95% CI 1.04-1.18) [8]. A higher dose of intranasal glucocorticoids had a stronger effect on symptom improvement. When used as an adjunct to antibiotic therapy in the treatment of ABRS, a meta-analysis of placebo-controlled trials suggests that 15 patients would need to be treated with intranasal glucocorticoids to improve clinical symptoms in one patient [5].

Other

Oral decongestants – Oral decongestants may be useful when eustachian tube dysfunction is a factor for patients with AVRS. These patients may benefit from a short course (three to five days) of oral decongestants. Oral decongestants should be used with caution in patients with cardiovascular disease, hypertension, angle-closure glaucoma, or bladder neck obstruction [9]. (See "Eustachian tube dysfunction" and "Eustachian tube dysfunction", section on 'Medical management'.)

In other patients, there is no evidence that oral decongestants are efficacious in decreasing symptoms of ARS and they have many adverse side effects (table 2) [4,5].

Intranasal decongestants – Intranasal decongestants are often used as symptomatic therapies by patients. These agents, such as oxymetazoline, may provide a subjective sense of improved nasal patency. However, there is no evidence to support their use for ARS [4,5]. There is also concern that intranasal decongestants themselves may provoke mucosal inflammation, at least in an experimental animal model [10]. If used, topical decongestants should be used sparingly for no more than three consecutive days to avoid rebound congestion, addiction, and mucosal damage associated with long-term use [11]. (See "An overview of rhinitis", section on 'Nasal decongestant sprays' and "Chronic nonallergic rhinitis", section on 'Medication-induced rhinitis'.)

Antihistamines Antihistamines are frequently used for symptom relief due to their drying effects; however, there are no studies investigating their efficacy for ARS [4,5]. Over-drying of the mucosa may lead to further discomfort. Additionally, antihistamines (particularly first generation medications) are often associated with adverse effects (drowsiness, xerostomia) [5]. (See "Pharmacotherapy of allergic rhinitis", section on 'Adverse effects and safety' and "Pharmacotherapy of allergic rhinitis", section on 'Adverse effects'.)

Mucolytics Mucolytics such as guaifenesin serve to thin secretions and may promote ease of mucus drainage and clearance; however, no published trials exist to support their use in ARS [4].

ACUTE BACTERIAL RHINOSINUSITIS — In addition to supportive care, options for the outpatient management of uncomplicated acute bacterial rhinosinusitis (ABRS) are observation or antibiotics depending on patient follow-up (algorithm 1).

Guidelines for the management of sinusitis have been issued by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) (2015) and the Infectious Disease Society of America (IDSA) (2012). Our recommendations for management are largely consistent with those of the AAO-HNS.

Natural history — Many patients with ABRS have self-limited disease that resolves without antibiotic therapy. Patients rarely develop complications of bacterial infection beyond the nasal cavity into the central nervous system, orbit, or surrounding tissues. Patients treated with antibiotics may have a shorter course of illness; however, they also experience more adverse events. (See 'Observation and symptomatic management' below and 'Antibiotics' below.)

Indications for urgent referral — Urgent, early referral is essential for patients with symptoms that are concerning for complicated ABRS or have evidence of complications on imaging. These include patients with high persistent fevers >102°F; periorbital edema, inflammation, or erythema; cranial nerve palsies; abnormal extraocular movements; proptosis; vision changes (double vision or impaired vision); severe headache; altered mental status; or meningeal signs. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Complications' and "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Complicated acute bacterial rhinosinusitis'.)

Observation and symptomatic management — We suggest observation (watchful waiting) with symptomatic management for immunocompetent patients with ABRS who have good follow-up (assurance that antibiotic therapy can be started if the patient does not improve or worsens) (algorithm 1) [4]. We start antibiotic therapy after diagnosis for patients who do not have good follow-up. The symptomatic management of ABRS is similar to that of acute viral rhinosinusitis (AVRS). (See 'Symptomatic therapies' above.)

Antibiotics should be started in patients who have been managed with observation who have worsening symptoms (algorithm 1). Patients with stable symptoms (no worsening or improvement) after 7 days may be managed either with an additional 10 days of observation and symptomatic management or antibiotic therapy depending on patient presentation, comorbidities, and social factors. Patients with worsening symptoms or who fail to improve with an additional 10 days of watchful waiting should be started on antibiotics. (See 'Antibiotics' below.)

There are also a variety of reasons for patients to have a suppressed immune system, and treatment decisions for immunocompromised patients should be made on a case by case basis. They may warrant immediate antibiotic treatment and/or specialist referral.

Guidelines from a multidisciplinary expert panel in 2015 recommend that patients with uncomplicated ABRS (regardless of severity of symptoms) may be managed symptomatically and observed if they have good follow-up [4]. The guidelines suggest that factors such as age, general state of health, and comorbidities should be considered when choosing this option. These guidelines differ from the 2012 IDSA guidelines in that the IDSA guidelines prefer prompt initiation of antibiotics with an option to withhold therapy for three days in patients with mild symptoms [5]. We prefer to provide an option for continued observation in patients with ABRS as many patients with ABRS improve without antibiotic therapy.

ABRS may be a self-limited disease and patients may improve without antibiotic therapy. Systematic reviews and meta-analyses have found that many patients with ABRS improve without antibiotic therapy within two weeks [12]. For example, a 2014 systematic review of randomized trials in immunocompetent patients with maxillary sinusitis found that 80 percent of patients not treated with antibiotics improved within two weeks [13]. Another 2012 systematic review of randomized trials involving immunocompetent patients with uncomplicated acute rhinosinusitis found that almost 50 percent of patients improved by one week, and 70 percent by two weeks, irrespective of antibiotic therapy [14]. Additionally, compared with placebo, patients who receive antibiotics have more adverse events [15]. However, the rates of spontaneous recovery for patients with ABRS are likely to be lower than reported in these analyses, as trials generally diagnose ABRS by clinical criteria and are likely to include some patients with AVRS. (See 'Antibiotics' below.)

Antibiotics — We start antibiotic therapy after diagnosis for patients who do not have good follow-up (algorithm 1 and algorithm 2). Antibiotics should also be started in patients who have been managed with observation who have worsening symptoms.

Patients with stable symptoms (no worsening or improvement) after 7 days may be managed either with an additional 10 days of observation and symptomatic management or antibiotic therapy depending on patient presentation, comorbidities, and social factors (algorithm 1 and algorithm 2). Patients with worsening symptoms or who fail to improve with an additional 10 days of watchful waiting should be started on antibiotics. (See 'Observation and symptomatic management' above.)

Treatment decisions for immunocompromised patients should be made on a case by case basis. They may warrant immediate antibiotic treatment and/or specialist referral.

Meta-analyses have consistently found that compared with placebo, patients with ABRS may benefit from antibiotics at the cost of increased adverse events [5,13,14,16,17]. Estimates of the number needed to treat to benefit range from 13 to 18 patients, while the number needed to harm is approximately 8 patients [4,5,14,16].

Other meta-analyses have estimated cure or symptom improvement. One meta-analysis found that compared with placebo, patients treated with antibiotics had a higher cure rate or symptom improvement at 7 to 15 days (odds ratio [OR] 1.64, 95% CI 1.35-2.0), with moderate magnitude of effect at the expense of an increase in adverse effects with antibiotic therapy [17]. Another found that compared with placebo, antibiotic therapy with penicillin or amoxicillin decreased clinical failure at 7 to 15 days (lack of full recovery or improvement) (risk ratio [RR] 0.66, 95% CI 0.47-0.94), but the clinical benefit was small and adverse events were more common with antibiotic treatment [13].

However, the studies in these meta-analyses have limitations. Many of the studies are likely to have included patients with AVRS as most studies used clinical criteria for diagnosis of ABRS without culture confirmation. Including patients with AVRS would make antibiotics appear less effective for ABRS. Also, studies have not generally distinguished the effectiveness of antibiotics based on symptom severity.

Additionally, comparative studies of antibiotics for the treatment of ABRS are limited as many studies likely include patients with AVRS. The significant rate of spontaneous recovery in studies decreases the ability of studies to differentiate between antibiotics (the apparent response to less-effective antibiotics is greater than would be seen in a more strictly defined ABRS population; conversely, the relative effectiveness of more appropriate antibiotics is diminished).

Initial oral therapy — Most patients with ABRS do not have culture data to guide antibiotic therapy and treatment is initiated empirically (algorithm 2). The choice of antibiotic is based on the most common bacteria associated with ABRS (table 3) as there is limited evidence to guide therapy [18-23]. Routine coverage for Staphylococcus aureus or methicillin-resistant S. aureus (MRSA) is not indicated at this time. Despite the prevalence of staphylococcal colonization in the middle meatus in health adults, S. aureus remains an uncommon cause of ABRS [24]. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Acute bacterial rhinosinusitis'.)

In light of increasing microbial resistance to antibiotics, we suggest initial empiric treatment with amoxicillin-clavulanate. We treat patients with risk factors for resistance with high-dose amoxicillin-clavulanate. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Acute bacterial rhinosinusitis'.)

Patients without risk factors for resistance Amoxicillin-clavulanate (500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily) is appropriate initial therapy for patients with ABRS who do not have risk factors for resistance (table 4 and algorithm 2) [4]. The addition of clavulanate to amoxicillin improves coverage for ampicillin-resistant H. influenzae as well as M. catarrhalis.

The evidence to support the use of amoxicillin-clavulanate rather than amoxicillin is stronger in children than adults [5]. However, there is increasing emergence of antimicrobial resistance among respiratory pathogens, including S. pneumococci and H. influenzae. Resistance rates vary regionally, with the prevalence of H. influenzae resistance ranging from 27 to 43 percent in the United States [5]. Additionally, the introduction of routine conjugated pneumococcal vaccination in children has changed the spectrum of bacterial infection. In both adults and children, the percentage of ABRS due to S. pneumoniae has decreased while the proportion due to H. influenzae has increased.

Patients with risk factors for resistance High-dose amoxicillin-clavulanate (2 g orally twice daily) is appropriate initial therapy for patients who are at higher risk for resistance (algorithm 2) [4,5]. Risk factors for resistance include (table 4):

Living in geographic regions with rates of penicillin-nonsusceptible S. pneumonia exceeding 10 percent. Local and regional histograms of bacterial resistance should be referenced to understand resistance trends in the local community.

Age ≥65 years.

Hospitalization in the last five days.

Antibiotic use in the previous month.

Immunocompromise.

Multiple comorbidities (eg, diabetes or chronic cardiac, hepatic, or renal disease).

Severe infection (eg evidence of systemic toxicity with temperature of ≥102°F, threat of suppurative complications).

Patients with penicillin allergyDoxycycline (100 mg orally twice daily or 200 mg orally daily) is a reasonable alternative for first-line therapy and can be used in patients with penicillin allergy (algorithm 2) [4,5]. A respiratory fluoroquinolone (levofloxacin 500 mg orally or moxifloxacin 400 mg orally once daily) is another option for penicillin-allergic patients.

For penicillin-allergic patients who can tolerate cephalosporins, clindamycin 150 mg or 300 mg every six hours plus a third-generation oral cephalosporin (cefixime 400 mg daily or cefpodoxime 200 mg twice daily) is an option for treatment.

Macrolides (clarithromycin or azithromycin), trimethoprim-sulfamethoxazole, and second- or third-generation cephalosporins are not recommended for empiric therapy because of high rates of resistance of S. pneumoniae (and of H. influenzae for trimethoprim-sulfamethoxazole) [4,5].

Antibiotic therapy for patients with nosocomial sinusitis and pregnant women with sinusitis are discussed separately. (See "Endotracheal tube management and complications", section on 'Sinusitis' and "Treatment of respiratory infections in pregnant women", section on 'Sinusitis'.)

Duration — Patients who are improving on initial therapy should be treated for a course of five to seven days [4,5]. Shorter courses (five to seven days) are reasonable as the available evidence suggests that response rates are similar to longer courses of antibiotics, and longer courses are associated with more adverse events [4,5].

In one meta-analysis of 12 randomized trials of ABRS in adults, no difference was noted in response rates or relapse rates comparing short courses (3 to 7 days) and longer courses (6 to 10 days) of antibiotics [25]. Rates of adverse events were lower for 5-day compared with 10-day courses. However, there was heterogeneity in the trials in terms of symptom duration and use of adjunctive medications.

Failure of initial oral therapy (second-line therapies) — Patients who have worsening symptoms or fail to improve within seven days on initial therapy should have the diagnosis of ABRS confirmed (algorithm 2) [4]. The diagnosis can be clinically confirmed if symptoms continue to be consistent with ABRS. While imaging is not indicated for patients with uncomplicated ABRS, imaging is reasonable in patients who fail initial therapy and whose symptoms are either not completely consistent with ABRS or are worrisome for possible complication to either confirm sinusitis and/or evaluate for alternative diagnosis. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Acute bacterial rhinosinusitis' and "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Supportive testing'.)

An alternative treatment strategy is indicated for patients with confirmed uncomplicated ABRS whose symptoms worsen or fail to show some improvement with seven days of antibiotic therapy [4].

Second-line therapies provide a broader spectrum of activity and/or are a different class of agent. Choice of therapy will depend on initial antibiotic therapy. There are limited data to guide second-line antibiotic choice [4,5]. Options include:

Amoxicillin-clavulanate 2000 mg/125 mg orally twice daily

Levofloxacin 500 mg orally once daily

Moxifloxacin 400 mg orally once daily

For penicillin-allergic patients, options for second-line therapy include:

Doxycycline 100 mg orally twice daily or 200 mg orally daily

Levofloxacin 500 mg orally once daily

Moxifloxacin 400 mg orally once daily

If improvement is seen within seven days of initiation of therapy, second-line therapy should be continued for a total course of 7 to 10 days.

Experimental evidence indicates bacterial eradication by day three [26,27] and studies have correlated clinical and bacteriologic response [28]. Although older adults or those with multiple comorbidities may take longer to resolve infection, such individuals should also show some symptom improvement within five days of initiating antibiotic therapy for ABRS [5]. Reasons for treatment failure include resistant pathogens, inadequate dosing, structural abnormalities, or a noninfectious etiology [5].

Failure of initial and second-line oral therapies — Patients should respond to second-line therapies within seven days of initiation. Patients who fail both initial and second-line therapies should have imaging and be referred for further evaluation (algorithm 2) [4,5]. A noncontrast computed tomography (CT) scan is appropriate in the evaluation of treatment-resistant sinusitis to evaluate for anatomic blockage [29]. Patients with anatomic abnormalities may require surgery. Patients should also be referred for sinus cultures either by direct aspirate or endoscopy of the middle meatus.

Relapse after oral therapy — Recurrence of symptoms within two weeks of response to initial oral treatment usually represents inadequate eradication of infection. Patients who had a good response to initial oral therapy and who have mild symptoms can be treated with a longer course of the same antibiotic. Patients whose relapse is moderate to severe, however, are more likely to have resistant organisms and require a change in the drug selected. (See 'Initial oral therapy' above and 'Failure of initial oral therapy (second-line therapies)' above.)

Patients with relapse should be treated for at least 7 to 10 days. If symptoms persist despite a repeat 7 to 10 day course of antibiotics, referral is warranted.

Systemic glucocorticoids — We suggest not using systemic glucocorticoids in the treatment of ABRS. When given in addition to antibiotics, oral glucocorticoids may shorten the time to symptom resolution or improvement. However, the benefits are small and, unlike topical glucocorticoids, systemic glucocorticoids possess a significant side effect profile. (See "Major side effects of systemic glucocorticoids".)

A 2014 systematic review and meta-analysis evaluated five randomized trials in adults with acute sinusitis (n = 1193). Four trials evaluated the benefits of glucocorticoids in addition to antibiotics (three trials compared antibiotics and glucocorticoids with antibiotics and placebo, one trial compared antibiotics and glucocorticoids with antibiotics and a nonsteroidal anti-inflammatory). One trial compared systemic glucocorticoids with placebo. Patients receiving steroids were more likely to have resolution or improvement in symptoms at three to seven days (RR 1.3, 95% CI 1.1-1.6) [30]. Another 2015 systematic review and meta-analysis included only the four trials where antibiotics were prescribed and had similar results (improved symptom control at three to seven days with steroids, RR 1.4, 95% CI 1.1-1.8) [31]. These data are limited by the potential for attrition bias and the lack of long-term follow-up on the effects of steroids.

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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient information: Sinusitis in adults (The Basics)" and "Patient information: What you should know about antibiotics (The Basics)")

Beyond the Basics topic (see "Patient information: Acute sinusitis (sinus infection) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Acute viral rhinosinusitis (AVRS) is expected to improve or resolve within 10 days. Patients with AVRS should be managed with supportive care. Patients who fail to improve after ≥10 days of symptomatic management are more likely to have acute bacterial rhinosinusitis (ABRS) and should be managed as ABRS. (See 'Acute viral rhinosinusitis' above.)

Symptomatic management of ARS aims to relieve symptoms of nasal obstruction and rhinorrhea. We suggest over-the-counter (OTC) analgesics and saline nasal irrigation (Grade 2C). We suggest treatment with intranasal glucocorticoids (Grade 2B). Decongestants may be useful when eustachian tube dysfunction is a factor for patients with AVRS but are not likely to be helpful for patients with ABRS and have adverse side effects. (See 'Symptomatic therapies' above.)

Urgent, early referral is essential for patients with symptoms that are concerning for complicated acute bacterial rhinosinusitis (ABRS) or have evidence of complications on imaging. (See 'Indications for urgent referral' above.)

ABRS may also be a self-limited disease. Systematic reviews and meta-analyses have found that 70 to 80 percent of immunocompetent patients improve within two weeks without antibiotic therapy. We suggest symptomatic management and observation (watchful waiting) for immunocompetent patients with ABRS who have good follow-up (algorithm 1) (Grade 2B). We start antibiotic therapy after diagnosis for patients who do not have good follow-up. (See 'Observation and symptomatic management' above and 'Symptomatic therapies' above.)

Antibiotics should be started in patients who have been managed with observation who have worsening symptoms (algorithm 1 and algorithm 2). Patients with stable symptoms (no worsening or improvement) after 7 days may be managed either with an additional 10 days of observation and symptomatic management or antibiotic therapy depending on patient presentation, comorbidities, and social factors. Patients with worsening symptoms or who fail to improve with an additional 10 days of watchful waiting should be started on antibiotics. (See 'Antibiotics' above.)

There are also a variety of reasons for patients to have a suppressed immune system, and treatment decisions for immunocompromised patients should be made on a case by case basis. They may warrant immediate antibiotic treatment and/or specialist referral.

In light of increasing microbial resistance to antibiotics, we suggest initial empiric treatment with amoxicillin-clavulanate rather than macrolides (clarithromycin or azithromycin), trimethoprim-sulfamethoxazole, or oral second- or third-generation cephalosporins (Grade 2B). (See 'Initial oral therapy' above.)

For patients without risk factors for resistance (table 4), we start with amoxicillin-clavulanate (either 500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily).

Patients with risk factors for resistance (table 4) should be treated with high-dose amoxicillin-clavulanate (2 g/125 mg orally twice daily).

Doxycycline (100 mg orally twice daily or 200 mg orally daily) is a reasonable alternative for first-line therapy and can be used in patients with penicillin allergy. A respiratory fluoroquinolone (levofloxacin 500 mg orally or moxifloxacin 400 mg orally once daily) is another option for penicillin-allergic patients. For penicillin-allergic patients who can tolerate cephalosporins, clindamycin 150 mg or 300 mg every six hours plus a third-generation oral cephalosporin (cefixime 400 mg daily or cefpodoxime 200 mg twice daily) is an option for treatment.

Patients who are improving on initial therapy should be treated for a course of five to seven days. (See 'Duration' above.)

Patients with ABRS are expected to show some response to empiric antimicrobial therapy within seven days. Patients who fail initial therapy should have the diagnosis of ABRS confirmed (algorithm 2). While imaging is not indicated for uncomplicated ABRS, imaging is reasonable in patients who fail initial therapy and whose symptoms are not completely consistent with ABRS to rule out sinusitis and/or evaluate for alternative diagnosis. (See 'Failure of initial oral therapy (second-line therapies)' above.)

An alternative treatment strategy is indicated for patients with confirmed uncomplicated ABRS whose symptoms worsen or fail to show some improvement in that time frame. Choice of therapy will depend on initial antibiotic therapy. Options for second-line empiric therapy include high-dose amoxicillin-clavulanate (2000 mg/125 mg orally twice daily) or a respiratory fluoroquinolone (levofloxacin 500 mg orally once daily or moxifloxacin 400 mg orally once daily).

For penicillin-allergic patients, options for second-line therapy include doxycycline 100 mg orally twice daily or 200 mg orally daily, levofloxacin 500 mg orally once daily, or moxifloxacin 400 mg orally once daily.

Patients who fail both initial and second-line therapies should have imaging and be referred for further evaluation (algorithm 2). (See 'Failure of initial oral therapy (second-line therapies)' above.)

Recurrence of symptoms within two weeks of response to initial treatment usually represents inadequate eradication of infection. (See 'Relapse after oral therapy' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Anne Getz, MD, who contributed to an earlier version of this topic review.

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