Principles of appropriate antibiotic use for acute rhinosinusitis: Background (reprinted from Annals of Internal Med, March 20, 2001)

The following principles of appropriate antibiotic use for adults with acut e rhinosinusitis apply to the diagnosis and treatment of acute maxillary an d ethmoid rhinosinusitis in adults who are not Immunocompromised. 1. Most cases of acute rhinosinusitis diagnosed in ambulatory care are caus ed by uncomplicated viral upper respiratory tract infections. 2. Bacterial and viral rhinosinusitis are difficult to differentiate on cli nical grounds. The clinical diagnosis of acute bacterial rhinosinusitis sho uld be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especiall y when unilateral) and purulent nasal secretions. Patients with rhinosinusi tis symptoms that last less than 7 days are unlikely to have bacterial infe ction, although rarely same patients with acute bacterial rhinosinusitis pr esent with dramatic symptoms of severe unilateral maxillary pain, swelling, and fever. 3. Sinus radiography is not recommended for diagnosis in routine cases. 4. Acute rhinosinusitis resolves without antibiotic treatment in most cases . Symptomatic treatment and reassurance is the preferred initial management strategy for patients with mild symptoms. Antibiotic therapy should be res erved for patients with moderately severe symptoms who meet the criteria fo r the clinical diagnosis of acute bacterial rhinosinusitis and for those wi th severe rhinosinusitis symptoms-especially those with unilateral facial p ain-regardless of duration of illness. For initial treatment, the most narr ow-spectrum agent active against the likely pathogens, Streptococcus pneumo niae and Haemophilus influenzae, should be used.