Management of complicated acute rhinosinusitis
Patients with complicated acute rhinosinusitis require intravenous antibiotic therapy and urgent surgical referral.
Complicated acute rhinosinusitis is often polymicrobial. The most common pathogens are Streptococcus anginosus (milleri) group (S. anginosus, S. constellatus, S. intermedius) and oral anaerobes.
The choice of antibiotic therapy for complicated acute rhinosinusitis depends on the duration of symptoms, the severity of systemic features, evidence of extension (eg meningitis, brain abscess) and other complicating factors (eg recent neurosurgery) – seek expert advice. For initial therapy while awaiting expert advice and the results of culture and susceptibility testing, use:
1ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously, 12-hourly1 ceftriaxone ceftriaxone ceftriaxone
OR
1cefotaxime 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see cefotaxime dosage adjustment cefotaxime cefotaxime cefotaxime
PLUS with either of the above regimens
metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 8-hourly. metronidazole metronidazole metronidazole
For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use one of the above regimens.
For patients who have had a severe (immediate or delayed)2 hypersensitivity reaction to a penicillin, seek expert advice.
For patients at increased risk of methicillin-resistant Staphylococcus aureus (MRSA), add vancomycin to the above regimen. Use:
vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for noncritically ill adults or Intermittent vancomycin dosing for young infants and children. vancomycin vancomycin vancomycin
For all patients with complicated acute rhinosinusitis, seek expert advice for ongoing management and duration of antibiotic therapy, and consider symptomatic therapy as for uncomplicated acute rhinosinusitis.