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Principles of Appropriate Antibiotic Use for Acute Rhinosinusitis in Adults: Background

John M. Hickner, MD, MSc; John G. Bartlett, MD; Richard E. Besser, MD; Ralph Gonzales, MD, MSPH; Jerome R. Hoffman, MA, MD; and Merle A. Sande, MD
[+] Article and Author Information

From Michigan State University, East Lansing, Michigan; Johns Hopkins University, Baltimore, Maryland; Centers for Disease Control and Prevention, Atlanta, Georgia; University of Colorado Health Sciences Center, Denver, Colorado; University of California, Los Angeles, Los Angeles, California; and University of Utah, Salt Lake City, Utah.


*After the primary author (Dr. Hickner), authors are listed in alphabetical order.

In addition to the Centers for Disease Control and Prevention, the principles outlined in this document have been endorsed by the American Academy of Family Physicians, the American College of Physicians–American Society of Internal Medicine, and the Infectious Diseases Society of America.

Annals of Internal Medicine encourages readers to copy and distribute this paper, providing such distribution is not for profit. Commercial distribution is not permitted without the express permission of the publisher.

Acknowledgments: External review has included feedback from the Centers for Disease Control and Prevention; the Clinical Efficacy Assessment Subcommittee; and representatives of the American Academy of Family Physicians, the American College of Emergency Physicians, and the Infectious Diseases Society of America.

Role of the Funding Source: The Centers for Disease Control and Prevention provided partial support for the development of the principles and required final approval of all manuscripts submitted for publication.

Requests for Single Reprints: Richard E. Besser, MD, Respiratory Diseases Branch (C-23), Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333; e-mail, rbesser@cdc.gov.

Current Author Addresses: Dr. Hickner: B111 Clinical Center, Michigan State University Department of Family Practice, East Lansing, MI 48824.

Dr. Bartlett: Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 463A, Baltimore, MD 21287-0003.

Dr. Besser: Respiratory Diseases Branch (C-23), Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333.

Dr. Gonzales: Campus Box B-180, 4200 East Ninth Avenue, Denver, CO 80262.

Dr. Hoffman: University of California, Los Angeles, 924 Westwood Boulevard, Los Angeles, CA 90024.

Dr. Sande: University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132.


Ann Intern Med. 2001;134(6):498-505. doi:10.7326/0003-4819-134-6-200103200-00017
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The following principles of appropriate antibiotic use for adults with acute rhinosinusitis apply to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in adults who are not immunocompromised.

1. Most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections.

2. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especially when unilateral) and purulent nasal secretions. Patients with rhinosinusitis symptoms that last less than 7 days are unlikely to have bacterial infection, although rarely some patients with acute bacterial rhinosinusitis present 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 reserved for patients with moderately severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis and for those with severe rhinosinusitis symptoms—especially those with unilateral facial pain—regardless of duration of illness. For initial treatment, the most narrow-spectrum agent active against the likely pathogens, Streptococcus pneumoniae and Haemophilus influenzae, should be used.

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