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When are antibiotics appropriate in ARS?1

Acute rhinosinusitis: When to prescribe an antibiotic1


Acute rhinosinusitis (ARS) is a major driver of antibiotic consumption. An estimated 30 million cases of ARS occur every year in the United States. More than 80% of people with ARS are prescribed antibiotics in North America, accounting for 15% to 20% of all antibiotic prescriptions in the adult outpatient setting. Many of these prescriptions are unnecessary, as the most common cause of ARS is a virus. 
But what about the minority who require antibiotic therapy? This article reviews how to evaluate patients with ARS, identify those who require antibiotics, and prescribe the most appropriate antibiotic treatment regimens.

Bacterial or viral infection?

ARS may be viral or bacterial in aetiology, with the most common bacterial organisms being Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Approximately 90% to 98% of cases of ARS are viral; only about 0.5% to 2% of viral rhinosinusitis episodes are complicated by bacterial infection.

Diagnostic criteria for acute bacterial rhinosinusitis (ABRS)

AAO-HNS: American Academy of Otolaryngology-Head and Neck Surgery; IDSA: Infectious Diseases Society of America.

Other symptoms that are significantly associated with ABRS are unilateral sinus pain and reported maxillary pain..

Selecting an appropriate treatment regimen

It is important to note that even after diagnosis of ABRS, a period of symptom management and watchful waiting is recommended. The rationale for treating ABRS with antibiotics is to expedite recovery and prevent complications such as periorbital or orbital cellulitis, meningitis, frontal osteomyelitis, cavernous sinus thrombosis, and other serious illness. Antibiotic treatment is associated with a shorter duration of symptoms (NNT=19) but an increased risk of adverse events (NNH=8).

Recommended treatment for acute bacterial rhinosinusitis

NSAID: nonsteroidal anti-inflammatory drug.


  • Overprescribing antibiotics for ABRS is a prominent healthcare issue.
  • Prescribers are encouraged to weigh the decision to treat ABRS with antibiotics against the risk for potential adverse reactions and within the context of antibiotic stewardship.
  • When prescribing antibiotics for ABRS, amoxicillin with or without clavulanic acid for 5–10 days is the first-line antibiotic therapy in adults and children.



  1. Hughes PR, Hungerford CH, Jensen KN. Acute rhinosinusitis: When to prescribe an antibiotic. J Fam Pract 2020;69(5):244–250.

    Article originally published June, 2020

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