Antibiotic regimens for uncomplicated acute rhinosinusitis

Uncomplicated acute rhinosinusitis is usually self-limiting, and antibiotic therapy makes little difference to the course of the illness. Only consider adding antibiotic therapy to symptomatic therapy for uncomplicated acute rhinosinusitis for patients whoNational Institute for Health and Care Excellence (NICE), 2017:

are systemically very unwell
have symptoms such as fever or facial pain that worsen after initially improving
do not improve after 10 days of symptomatic therapy.

Note: Uncomplicated acute rhinosinusitis is usually self-limiting, and antibiotic therapy makes little difference to the course of the illness.

The usual pathogens in uncomplicated acute bacterial rhinosinusitis are Streptococcus pneumoniae and Haemophilus influenzae; Moraxella catarrhalis is less common.

For antibiotic management of uncomplicated acute rhinosinusitis, use:

1amoxicillin 500 mg (child: 15 mg/kg up to 500 mg) orally, 8-hourly for 5 days. For dosage adjustment in adults with kidney impairment, see amoxicillin dosage adjustment amoxicillin amoxicillin amoxicillin

OR if adherence to an 8-hourly regimen is unlikely

1amoxicillin 1 g (child: 30 mg/kg up to 1 g) orally, 12-hourly for 5 days. For dosage adjustment in adults with kidney impairment, see amoxicillin dosage adjustment. amoxicillin amoxicillin amoxicillin

Do not use lower amoxicillin doses because they will not achieve adequate plasma and tissue concentrations to treat S. pneumoniae strains with intermediate susceptibility to penicillins.

For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use:

cefuroxime 500 mg (child 3 months or older: 15 mg/kg up to 500 mg) orally, 12-hourly for 5 days¹. For dosage adjustment in adults with kidney impairment, see cefuroxime dosage adjustment. cefuroxime cefuroxime cefuroxime

For patients who have had a severe (immediate or delayed)² hypersensitivity reaction to a penicillin, or if a suitable formulation of cefuroxime is not available, use:

doxycycline orally, 12-hourly for 5 days³ doxycycline doxycycline doxycycline

adult: 100 mg

child less than 21 kg: 2.2 mg/kg⁴

child 21 to less than 26 kg: 50 mg

child 26 to 35 kg: 75 mg

child more than 35 kg: 100 mg.

Ask the patient to return for review and reassessment of the diagnosis if symptoms of uncomplicated acute rhinosinusitis do not improve after 5 days of antibiotic therapy, or earlier if symptoms worsen (particularly fever) or if symptoms of complicated rhinosinusitis develop (see Clinical features of acute rhinosinusitis that indicate spread of infection beyond the paranasal sinuses). Patients with complicated rhinosinusitis require intravenous antibiotic therapy and urgent surgical referral – see Management of complicated acute bacterial rhinosinusitis.

¹ Cefuroxime is preferred to cefalexin or cefaclor because of its superior antipneumococcal activity; see Practical information on using beta lactams: cephalosporins for further information.Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse. Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return

³ An oral liquid formulation of doxycycline is not marketed in Australia but is available via the Special Access Scheme. For formulation options for children or people with swallowing difficulties, see Don’t Rush to Crush, which is available for purchase from the Advanced Pharmacy Australia website or through a subscription to eMIMSplus.Return

⁴ When used short term (eg less than 21 days), doxycycline has not been associated with tooth discolouration, enamel hypoplasia or bone deposition so can be used in children of all ages.Return