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Acute bacterial rhinosinusitis

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Updated 2025 AAFP guidelines for the management of acute bacterial rhinosinusitis .

Background

Overview

Definition
ABRS, also known as acute sinusitis, is an inflammation of the nasal cavity and paranasal sinuses that lasts up to 4 weeks.
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Pathophysiology
ABRS is mostly caused by S. pneumoniae, Haemophilus influenza, and M. catarrhalis.
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Disease course
Nasal and paranasal infection results in ABRS, which causes clinical manifestations of nasal congestion and obstruction, purulent nasal discharge, facial pain or pressure, fever, fatigue, cough, hyposmia, ear pressure, headache, and halitosis. Disease progression may result in orbital and CNS complications.
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Prognosis and risk of recurrence
ABRS with ocular complications is associated with a 3.17% mortality rate.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute bacterial rhinosinusitis are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2025), the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS2020 2020), the American College of Physicians (ACP/CDC 2016), the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF ...
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Screening and diagnosis

Diagnostic criteria
As per AAO-HNSF 2015 guidelines:
Diagnose ABRS in patients with:
symptoms or signs of acute rhinosinusitis (purulent nasal drainage accompanied by nasal obstruction, facial pain/pressure/fullness, or both) persisting without evidence of improvement for ≥ 10 days after the onset of symptoms
symptoms or signs of acute rhinosinusitis worsening within 10 days after an initial improvement (double worsening)
B
Distinguish chronic rhinosinusitis and recurrent acute rhinosinusitis from isolated episodes of ABRS and other causes of sinonasal symptoms.
B
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Diagnostic investigations

Diagnostic imaging: as per AAFP 2025 guidelines, do not routinely obtain imaging to distinguish between viral and bacterial rhinosinusitis.
D

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  • Sinus culture

Medical management

Antibiotic therapy, initiation: as per AAFP 2025 guidelines, reserve antibiotics for patients with rhinosinusitis presenting with fever, facial pain, and purulent nasal drainage persisting for 7-10 days, exhibiting improvement followed by worsening of symptoms (double-sickening), or experiencing severe symptoms lasting ≥ 3 days.
B

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  • Antibiotic therapy (first-line)

  • Antibiotic therapy (second-line)

  • Antibiotic therapy (MRSA coverage)

  • Antibiotic therapy (duration)

  • Symptomatic treatment

  • Management of nonresponse to treatment

Specific circumstances

Pediatric patients: as per IDSA 2012 guidelines, administer amoxicillin/clavulanate over amoxicillin alone as empiric antimicrobial therapy in pediatric patients with ABRS. (strong, moderate) Administer high-dose (90 mg/kg/day PO BID) amoxicillin/clavulanate in pediatric patients with ABRS from geographic regions with high endemic rates (≥ 10%) of invasive penicillin-nonsusceptible S. pneumoniae, those with severe infection (evidence of systemic toxicity with fever ≥ 39 °C, and threat of suppurative complications), attendance at daycare, age < 2 years, recent hospitalization, antibiotic use within the past month, or immunocompromised condition.
B
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Follow-up and surveillance

Indications for specialist referral: as per IDSA 2012 guidelines, obtain specialist consultation with an otolaryngologist, infectious disease specialist, or allergist in the following situations:
patients who are seriously ill and immunocompromised
patients who continue to deteriorate clinically despite extended courses of antimicrobial therapy
patients who have recurrent bouts of acute rhinosinusitis with clearing between episodes.
B

More topics in this section

  • Evaluation of recurrent acute rhinosinusitis