Acute Bacterial Rhinosinusitis (ABRS) – Evidence‑Based Management

Initial Decision‑Making

Watchful waiting is appropriate for uncomplicated ABRS when reliable follow‑up can be ensured; 86 % of patients improve with placebo within 7–15 days. (American Academy of Otolaryngology) 3
Initiate antibiotics only if symptoms persist beyond 7 days or worsen at any time. (American Academy of Otolaryngology) 4

Amoxicillin (with or without clavulanate) for 5–10 days is the recommended first‑line regimen for most adult patients. (American Academy of Otolaryngology) 4
Plain amoxicillin suffices for uncomplicated cases without risk factors for resistant organisms. (American Academy of Otolaryngology) 5
Amoxicillin‑clavulanate should be used when β‑lactamase‑producing pathogens are suspected or in patients with chronic lung disease. (American Academy of Otolaryngology) 4

Re‑evaluate the patient at day 7 if no clinical improvement to confirm the diagnosis and exclude complications. (American Academy of Otolaryngology) 4
If the patient was initially observed without antibiotics, start an appropriate antibiotic at that point. (American Academy of Otolaryngology) 5
If the patient is already on antibiotics and shows no improvement, switch to an alternative agent. (American Academy of Otolaryngology) 4

Amoxicillin 500–1000 mg every 8 hours is the first‑choice agent for adults without risk factors, administered for 5–7 days. (Indian national guideline synthesis) 1

Switch to amoxicillin‑clavulanate if any of the following are present:
- High local prevalence of β‑lactamase‑producing Haemophilus influenzae
- Chronic lung disease (e.g., COPD, bronchiectasis)
- Recent exposure to antibiotics
- Documented failure of plain aminopenicillin therapy

Macrolide (clarithromycin 250–500 mg twice daily). (Indian national guideline synthesis) 2
Tetracycline (doxycycline 100 mg twice daily), especially in smokers. (Indian national guideline synthesis) 2
Oral cephalosporin for non‑anaphylactic penicillin allergy. (Indian national guideline synthesis) 2
Respiratory fluoroquinolones are reserved for treatment failures or complicated infections. (Indian national guideline synthesis) 2

Do not use cefuroxime as automatic first‑line therapy in patients with chronic lung disease or recent antibiotic exposure; amoxicillin‑clavulanate is superior in these scenarios. (Indian national guideline synthesis) 1
Avoid oral cephalosporins when β‑lactamase‑producing organisms are suspected. (Indian national guideline synthesis) 1

Respiratory rate ≥ 30 breaths/min, temperature < 35 °C or ≥ 40 °C, heart rate ≥ 125 beats/min, blood pressure < 90/60 mmHg, cyanosis, or altered mental status/confusion. (Indian national guideline synthesis) 6

Re‑assess if fever persists beyond 48 hours after initiating therapy. (Indian national guideline synthesis) 1
Explain that cough may continue after the antibiotic course ends and does not necessarily indicate treatment failure. (Indian national guideline synthesis) 1

Amoxicillin or amoxicillin‑clavulanate for 5–7 days is advised for uncomplicated bacterial tracheitis without additional risk factors. (Indian national guideline synthesis) 6
Use amoxicillin‑clavulanate in patients with chronic lung disease or when β‑lactamase‑producing organisms are a concern. (Indian national guideline synthesis) 6

Macrolide (azithromycin) or tetracycline (doxycycline) can be employed. (Indian national guideline synthesis) 6
Oral cephalosporins are appropriate for non‑anaphylactic penicillin allergy. (Indian national guideline synthesis) 6
Respiratory fluoroquinolones should be reserved for cases where initial therapy fails. (Indian national guideline synthesis) 6