¹ One or more severe symptoms present for less than 7 days which may prompt early antibiotic therapy may include the following: temperature > 102�; unilateral facial pain or pressure; bilateral facial pain, which may suggest pan-sinusitis; facial erythema; swelling over the sinus; maxillary teeth pain; and/or bimodal disease course.

² Stronger consideration for initiating prompt antibiotic therapy should be given in the case of immunocompromised patients with symptoms of less than 7 days duration; clinical judgment should prevail in such cases, and earlier referral to ENT may be necessary.

³ Other beta-lactam antibiotics also may be considered, among them: cefpodoxime, cefuroxime, loracarbef, and ceftibuten.

⁴ Because of increasing resistance to amoxicillin among S. pneumoniae isolates from patients with bacterial respiratory tract infections, high-dose amoxicillin therapy is recommended for treatment of acute bacterial rhinosinusitis in adults. In addition, amoxicillin also is preferred as an initial agent when acquisition of the antibiotic may be compromised by cost considerations, resulting in medication noncompliance.

⁵ Fluoroquinolones are effective and safe agents for the treatment of acute bacterial rhinosinusitis, and produce similar outcomes when evaluated against comparator agents. However, recent practice guidelines for bacterial respiratory tract infections from the Infectious Disease Society of America (IDSA) and Centers for Disease Control and Prevention (CDC) note that effecting positive outcomes with potent, excessively broad-spectrum agents must be balanced against the pitfalls of inducing resistance to such agents, especially fluoroquinolones. In its Dec. 1, 2003, Practice Update Guidelines for community-acquired pneumonia (CAP), the IDSA committee expressed concern about misuse and over-use of fluoroquinolones, noting that if abuse of this class of drugs continues unabated, we may see the demise of fluoroquinolones as useful antibiotics within the next 5-10 years (Clin Infect Dis. 2003;37:1405-1433).

⁶ Doxycycline should be considered as an alternative agent when acquisition of the antibiotic may be compromised by cost considerations, resulting in medication noncompliance.

⁷ If a patient with presumed acute bacterial rhinosinusitis has received a previous course of antimicrobial therapy with either a beta-lactam (cefuroxime, amoxicillin, amoxicillin/clavulanate, etc.) or a macrolide within the past 3 months, excluding the current episode, a respiratory fluoroquinolone (i.e., moxifloxacin, levofloxacin) is recommended as the initial treatment. Conversely, recent use of a fluoroquinolone should dictate use of either an advanced generation macrolide (azithromycin or clarithromycin) or a beta-lactam (amoxicillin/clavulanate).

⁸ Among the advanced generation, respiratory fluoroquinolones, moxifloxacin is preferred because it has lower minimum inhibitory concentration levels against S. pneumoniae than levofloxacin, and because it has a more narrow (gram-positive organism-focused) spectrum of coverage.