What type of antibiotics for upper respiratory infection

Upper respiratory infections and acute bacterial rhinosinusitis in adults and children often have similar symptoms. The main pathogens are identical to those that cause acute otitis media: Streptococcus pneumoniae , nontypeable Haemophilus influenzae , and Moraxella catarrhalis. A diagnosis of acute bacterial rhinosinusitis may be made in children and adults with symptoms of a viral upper respiratory infection that have not improved after 10 days or that worsen after five to seven days.

Because many of these signs and symptoms are nonspecific, accurate diagnosis of acute bacterial rhinosinusitis is challenging. A validated clinical decision rule for adults that combines several symptoms is shown in Table 3. The rightsholder did not grant rights to reproduce this item in electronic media.

For the missing item, see the original print version of this publication. The Sinus and Allergy Health Partnership issued guidelines targeting patients with mild to moderate disease. Treatment is reserved for patients who have symptoms for more than 10 days or who experience worsening symptoms. Type I immunoglobulin E—mediated reactions can lead to anaphylaxis and angioedema.

TMP-SMX, doxycycline Vibramycin , azithromycin Zithromax , or clarithromycin Biaxin is recommended if the patient has a history of type I hypersensitivity reaction to betalactam antibiotics.

If the patient does not respond to antimicrobial therapy after 72 hours, he or she should be reevaluated and a change in antibiotics should be considered. Diagnostic evaluations such as computed tomography, fiberoptic endoscopy, or sinus aspiration also may be necessary for patients who experience a treatment failure.

Most patients with sore throat from an infectious cause have a virus. Symptoms that suggest a viral etiology for sore throat include conjunctivitis, cough, coryza, and diarrhea. Group A beta-hemolytic streptococcus GABHS pharyngitis accounts for 15 to 30 percent of pharyngitis cases in children and approximately 10 percent in adults.

An evidence-based guideline sponsored by the American College of Physicians ACP and the CDC provides a somewhat different approach to antibiotic use and laboratory testing in adults with acute tonsillopharyngitis.

Absence of cough. Cervical adenopathy. Tonsillar exudates. Total score:. Using the strep score, GABHS pharyngitis can be ruled out clinically in low-risk patients and no further testing is needed. Moderate-risk patients need rapid antigen testing to confirm the diagnosis before therapy is initiated, whereas empiric therapy can be considered for high-risk patients. Throat culture is recommended only in an outbreak situation as a method of epidemiologic study and for patients in whom gonococcal disease is possible.

However, amoxicillin is an acceptable alternative because of taste and the increased likelihood of compliance. Alternative antimicrobials include first- or second-generation cephalosporins, clindamycin, or macrolides.

Bronchitis is inflammation of the bronchial respiratory mucosa leading to a productive cough. The diagnosis is based on clinical findings, and no objective test exists.

Sputum characteristics i. If pneumonia is suspected based on tachypnea, high fever, asymmetric breath sounds, or other symptoms, the diagnosis should be confirmed with chest radiography before antibiotics are prescribed. The results of recent randomized controlled trials support this recommendation.

For example, in one study, patients diagnosed with acute bronchitis were randomized to treatment with azithromycin or placebo vitamin C. Another study of patients with acute lower respiratory tract infection, including many with fever or purulent sputum, compared treatment outcomes with an immediate antibiotic, a delayed antibiotic, or no antibiotic.

No significant differences were noted between groups, and the researchers concluded that no antibiotics and delayed antibiotics were both acceptable approaches. If the cough is prolonged for more than 10 days, a bacterial etiology should be considered. The CDC recommends azithromycin for five days, clarithromycin for seven days, or erythromycin for 14 days in children older than one month and in adults with suspected pertussis based on recent exposure or for postexposure prophylaxis.

For children younger than one month, azithromycin is recommended. Nonspecific upper respiratory tract infection presents with symptoms that often are referred to as the common cold. Antibiotics are not needed in these circumstances. Treatment consists of adequate fluid intake, rest, humidified air, and over-the-counter analgesics and antipyretics. Influenza is characterized by the abrupt onset of fever, myalgias, headache, rhinitis, severe malaise, nonproductive cough, and sore throat.

The main treatment is supportive care to relieve symptoms. Antiviral medications i. Patients often expect an antibiotic for an acute respiratory infection; because health care professionals strive for patient satisfaction, they may feel pressured to prescribe an unnecessary antibiotic. If the diagnosis is a viral illness, the physician needs to have a contingency plan to explain to the patient why an antibiotic will not be prescribed.

Patients should be educated about the difference between bacterial and viral infections and why antibiotics will be ineffective for a viral illness. Targeted symptomatic relief can be provided with antipyretics, decongestants, antihistamines, and antitussives. Having prescription pads with a preprinted checklist of medications for symptomatic relief and patient education is useful.

Several studies have indicated that giving patients an antibiotic prescription and telling them not to fill it unless their symptoms worsen or do not improve after several days has been shown to reduce antibiotic use.

An educational intervention such as instructing patients on the appropriate indications for antibiotic use can help maintain patient satisfaction without prescribing antibiotics. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Wong received his medical degree from the Kirksville Mo. College of Osteopathic Medicine. Blumberg completed a residency in pediatrics at Massachusetts General Hospital, Boston, and a pediatric infectious diseases fellowship at the University of California, Los Angeles.

Address correspondence to David M. Wong, D. Reprints are not available from the authors. Author disclosure: Dr. Blumberg has received grant support for research from Merck and has been part of speaker's bureaus for Merck, GlaxoSmithKline, and Wyeth.

Antimicrobial drug prescription in ambulatory care settings, United States, — [Published correction appears in Emerg Infect Dis ;].

Emerg Infect Dis. Changing use of antibiotics in community-based outpatient practice, — Ann Intern Med. Cochrane Database Syst Rev. Antibiotic use in acute upper respiratory tract infections Am Fam Physician.

Antibiotics for acute bronchitis. J Korean Med Sci. US emergency department visits for outpatient adverse drug events, Issa I, Moucari R. Probiotics for antibiotic-associated diarrhea: Do we have a verdict? World Journal of Gastroenterology. Your Privacy Rights. To change or withdraw your consent choices for VerywellHealth. At any time, you can update your settings through the "EU Privacy" link at the bottom of any page.

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Some practitioners may believe that prescribing antimicrobials is quicker than fulfilling these expectations, although no investigations evaluated the time involved with these different strategies or the patients' assessment of such behavior.

Two studies of pharyngitis, however, showed that those not receiving antibiotics were less likely to return for subsequent episodes than those who did, although both groups were equally satisfied. Physicians who educate patients in this way may actually reduce their workload. Promiscuous prescribing of antibiotics substantially increases the cost of medical care, but it has a more pernicious effect.

Antimicrobials are unique among medicines in that their excessive use, especially of those with a broad spectrum of antibacterial activity, can lead to decreased efficacy, as bacteria become resistant throughout the community. Unsurprisingly, the widespread indiscriminate administration of antibiotics that is common now has diminished the susceptibility of respiratory flora. Except where noted, the available information indicates that antibiotics provide little or no benefit for disorders reviewed here, which account for nearly half of adult outpatient antibiotic use.

Rather than prescribing antimicrobials, practitioners should explain that these ailments are rarely serious; they spontaneously abate, albeit sometimes slowly; antibiotics do not hasten resolution, but often make patients decidedly worse; and treating symptoms by other means frequently helps. For nasal and sinus complaints, vasoconstricting nasal sprays or drops such as oxymetazoline are reasonable, and, in acute bronchitis, antitussives may diminish coughing.

Inhaled bronchodilators are often beneficial for dyspnea, wheezing, or severe cough in acute bronchitis and are indicated, along with oral corticosteroids, for exacerbations of asthma and chronic obstructive lung disease.

Using terminology that suggests a viral cause may also help, since many patients understand that antibiotics are ineffective for viral infections: practitioners should use diagnoses such as "viral sore throat" and "chest cold" rather than "acute bronchitis," and "sinus cold" rather than "acute sinusitis.

Corresponding author and reprints: J. Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy Continue. Osler W Recent advances in medicine. Gonzales RSteiner JFSande MA Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians.

J Fam Pract. Jacoby GA Prevalence and resistance mechanisms of common bacterial respiratory pathogens. Clin Infect Dis. Cohen ML Epidemiology of drug resistance: implications for a post-antimicrobial era. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Engl J Med. Kristinsson KG Effect of antimicrobial use and other risk factors on antimicrobial resistance in pneumococci. Microb Drug Resist. Williamson HA A randomized, controlled trial of doxycycline in the treatment of acute bronchitis.

Scand J Prim Health Care. Am J Epidemiol. Foy HM Infections caused by Mycoplasma pneumoniae and possible carrier state in different populations of patients. Evidence that Chlamydia pneumoniae causes pneumonia and bronchitis.

J Infect Dis. Respir Med. Am Rev Respir Dis. Effectiveness of short-course therapy 5 days with cefuroxime axetil in treatment of secondary bacterial infections of acute bronchitis. Antimicrob Agents Chemother. J Clin Microbiol. Hirschmann JVEverett ED Haemophilus influenzae infections in adults: report of nine cases and review of the literature.

Medicine Baltimore. J Ky Med Assoc. Br J Gen Pract. Arch Fam Med. MacKay DN Treatment of acute bronchitis in adults without underlying lung disease. J Gen Intern Med. Am J Med. Fahey TStocks NThomas T Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults. Hueston WJ Albuterol delivered by metered-dose inhaler to treat acute bronchitis. Fam Pract. Respiratory tract viral infections in inner-city asthmatic adults.

Clarke CW Relationship of bacterial and viral infections to exacerbations of asthma. Ann Allergy. Acute exacerbations of asthma in adults: role of Chlamydia pneumoniae infection. Eur Respir J. Ann Allergy Asthma Immunol. J Allergy Clin Immunol. Randomised comparison of guided self management and traditional treatment of asthma over one year. American Thoracic Society, Definitions and classification of chronic bronchitis, asthma, and pulmonary emphysema.

Chlamydia pneumoniae infection in acute exacerbations of COPD. A study of infective and other factors in exacerbations of chronic bronchitis. Br J Dis Chest. Exacerbations of chronic bronchitis: treatment with oxytetracycline. Quality of evidence: High, Strength of recommendation: Weak. Acute bacterial pharyngotonsillitis may recur despite antibiotic therapy owing to inappropriate use of antibiotics, insufficient antibiotic dosage or treatment duration, low patient compliance, re-infection, and though rare, penicillin resistance [ 72 , 73 ].

Further, it may be considered for cases in which S. Bacterial culture should be performed after completion of antibiotic therapy for S. Culture should generally be performed within 2—7 days of treatment completion. Because treatment failure and chronic carriers must be distinguished [ 65 ], antibiotics should not be administered again if the symptoms have improved, even if a bacterial strain is isolated in the follow-up test. However, patients with a history or family history of rheumatic fever are subject to retreatment even if they are asymptomatic.

If symptoms persist, first-line antibiotics may be used more than once, and benzathine penicillin G may be considered for patients with low compliance; however, established data is lacking.

Broad-spectrum cephalosporins e. Moreover, 5-day cefaclor therapy and day amoxicillin therapy had similar treatment effects [ 76 ]. On the other hand, the treatment responses of day cefaclor therapy were superior to those of day erythromycin treatment, which has been reported to be attributable to macrolides-resistant S. In addition, the treatment responses of 5-day cefditoren pivoxil therapy and day amoxicillin therapy were not significantly different [ 78 ].

Previous RCTs have investigated whether antibiotic therapy for patients with acute pharyngotonsillitis reduces the incidence of future episodes of pharyngotonsillitis and whether prophylactic antibiotic therapy reduces recurrent episodes of pharyngotonsillitis [ 73 , 79 , 80 ].

In one study, prophylactic use of benzathine penicillin G in children led to a lower incidence of S. Prolonged azithromycin therapy as an alternative to tonsillectomy was ineffective in treating frequent recurrent tonsillitis [ 73 ]. In summary, one of three previous studies have suggested that prophylactic antibiotic therapy is ineffective, and the remaining two studies have showed that it has small but statistically significant effects.

However, it is difficult to generalize these findings due to their methodological limitations. These studies also reported that the use of cephalosporin for treatment and prevention purposes lowered the incidence of sore throat but that macrolide, such as azithromycin, did not produce similar effects [ 79 , 80 ].

In such cases, the patient should be referred to a specialist to determine whether surgical treatment is indicated. Quality of evidence: Very low, Strength of recommendation: Strong. Peritonsillar abscess is the most common deep neck infection. Other deep neck infections include parapharyngeal abscess and retropharyngeal abscess, and infection of the parapharyngeal space may occur as a complication of pharyngitis [ 81 , 82 , 83 , 84 ].

Furthermore, these diseases must be differentiated from pharyngotonsillitis from the beginning. Peritonsillar cellulitis or phlegmon is a term used for cases in which the peritonsillar space is infected without the formation of an abscess. The most important management strategy for deep neck infection is airway assessment and management [ 26 ].

For patients who are restless, have swallowing difficulty, and are drooling, the airway should be closely observed to ensure patency. Further, patients should be assessed to determine whether they need procedures such as intubation and if so, proper procedures should be performed before referring them to a specialist [ 86 ].

Serious clinical symptoms and signs are listed in Table 4. Ultrasound or computed tomography CT may be required. Ultrasound should be performed by a skilled expert. Although CT is associated with the potential adverse effects of radiation exposure and use of contrasting agents, it can be performed quickly if the facility is equipped with a CT scan and it provides objective images. CT is commonly performed for diagnosis and differential diagnosis from other diseases [ 83 , 84 ].

Magnetic resonance imaging MRI may also be used [ 83 ]. Abscess in the neck is associated with the teeth in many adults; it is more common as a complication of tonsillitis among children, adolescents, and young adults [ 26 , 81 , 82 , 83 , 84 ].

Immunocompromised individuals may have non-responsive tonsillitis caused by various unusual pathogens, so it is important to refer them to a specialist for a broader approach to identifying the cause and for effective treatment [ 87 , 88 ].

Table 5 shows a comparison of this guideline with Korean Guidelines for the Antibiotic Use in Children with Acute Upper Respiratory Tract Infection and other major guidelines for acute pharyngotonsillitis caused by S.

Antibiotics may be prescribed early after diagnosis of acute bacterial sinusitis. Empirical antimicrobial therapy should be initiated when the patient shows no improvement of symptoms within 7 days of diagnosis of acute bacterial sinusitis or shows exacerbation of symptoms. Sinusitis is an inflammation of the nasal passage and mucosa lining the sinuses resulting from infection, allergy, and autoimmunity.

Because it is usually accompanied by inflammation of the nasal cavity and paranasal sinuses, sinusitis is also commonly referred to as rhinosinusitis [ 94 ]. Sinusitis may be classified according to the main site of infection such as maxillary, frontal, ethmoid, and sphenoid sinusitis; it is also classified according to the stage of infection, such as acute less than 4 weeks , subacute 4 weeks—3 months , and chronic more than 3 months [ 95 ].

Moreover, sinusitis can be classified into community-acquired, healthcare-associated, and nosocomial infection depending on the location of pathogen exposure. More detailed definitions of acute sinusitis are given in Table 6 [ 94 , 95 , 96 , 97 ]. In addition to identifying the infectious causes of sinusitis, differentiating the noninfectious causes is important, such as in vasomotor and atrophic sinusitis as well as the recently increasing allergic sinusitis [ 98 ]. Infectious causes of sinusitis encompass a variety of microorganisms, including viruses, bacteria, or fungal organisms.

About 0. Bacterial pathogens that have been identified with needle biopsies of maxillary sinus specimens in patients with acute sinusitis include S. Other known viral pathogens include rhinovirus, parainfluenza virus, and influenza virus; though rare, fungal pathogens, such as Aspergillus, zygomycetes, Phaeohyphomycis, Pseudallescheria, and Hyalohyphomycis have also been identified [ , ]. However, bacterial sinusitis generally requires antibiotic therapy because the sinuses are normally a sterile environment.

In addition, certain types of acute bacterial sinusitis may lead to severe complications, such as bacterial encephalomeningitis, brain abscess, and periocular tissue infection. Further, the possibility of chronic sinus disease cannot be completely eliminated [ , ]. However, inappropriate antibiotic therapy increases antimicrobial resistance and drug side effects, thereby elevating medical costs. This situation calls for efforts to differentiate acute viral and bacterial sinusitis in the clinical setting [ ].

Unfortunately, it is very difficult to differentiate acute viral sinusitis from acute bacterial sinusitis in the clinical setting owing to the low agreement among examination, imaging, and laboratory findings that are used for diagnosis in addition to the clinical symptoms of acute sinusitis, such as nasal congestion, nasal drainage, sneezing, and nose itching [ , ].

Nevertheless, clinicians must try to differentiate viral and bacterial sinusitis based on the symptoms and signs as well as the typical manifestations and chronological changes of symptoms [ ]. Although needle aspiration cultures of sinus specimens may be performed to diagnose acute bacterial sinusitis, clinicians generally make clinical diagnoses because this method is an invasive technique that cannot be performed in the clinical setting.

Clinical diagnosis of acute bacterial sinusitis generally requires progress observation for 7 days, and radiologic testing may aid in clinical diagnosis if symptoms such as purulent nasal drainage, unilateral maxillary toothache, facial pain, and unilateral tenderness of the maxillary sinus improve initially but worsen over time [ 4 , ]. According to guideline recommendations, when double sickening, such as new fever, headache, and increased nasal drainage, begins after acute viral upper respiratory infection symptoms had begun to improve 5—6 days after symptom onset, acute bacterial sinusitis should be suspected and antibiotic therapy initiated [ ].

In addition, foul smelling discharge is suggestive of anaerobic bacterial infection, and clinicians should assess the possibility of tooth infections and begin antibiotic therapy. And the duration of pain or morbidity were not correlated with initial treatment for acute bacterial sinusitis [ 94 , 96 ]. Therefore, antibiotics may be prescribed during primary care for patients with acute bacterial sinusitis without complications; however, clinicians may also delay initial antibiotic therapy and opt for a watchful waiting approach depending on the case at hand.

However, early antibiotic therapy should only be delayed in cases where the clinician is confident that the patient will attend follow-up appointments [ 94 ]. Empirical antibiotic therapy should be initiated in cases where the patient shows no improvement of symptoms or when symptoms worsen within 7 days of proper non-antibiotic, symptomatic treatment after the diagnosis of acute bacterial sinusitis [ , ]. Flowchart for early use of empirical antibiotic therapy in patients with acute bacterial sinusitis.

Patients allergic to penicillin: for patients with type 4 hypersensitivity e. For type 1 hypersensitivity e. Non-beta-lactam antibiotics should be used. To choose the appropriate antibiotics for acute bacterial sinusitis, the main causative pathogen and its antibiotic susceptibility must be considered.

Although there are no Korean epidemiological data on the causative pathogens of acute bacterial sinusitis, data from other countries show that S. However, epidemiological changes are anticipated in Korea in response to the progressive rise in the pneumococcal vaccination rate [ ]. Among clinical isolates taken from patients who visited primary care clinics for sinusitis between and in the United States, the sensitivity of S.

There are two RCTs and one systematic literature review pertaining to the possible first-line empirical antibiotics for acute sinusitis. Although adults are at lower risk of acute bacterial sinusitis caused by M. For patients with type 4 penicillin allergy e. For patients with type 1 allergy e. Only non-beta-lactams should be used e. Foreign data reveal that the main pathogens of acute sinusitis, namely S.

According to a review of 12 RCTs that investigated the duration of antibiotic therapy for patients radiologically diagnosed with acute sinusitis, there were no significant differences in the treatment success rate between the short-duration antibiotic therapy group 3—7 days and long-duration antibiotic therapy group 6—10 days [ ].

Moreover, the long-duration antibiotic therapy group more than 10 days had higher incidences of adverse drug responses than other groups [ , ]. As stated in the treatment guideline for children, additional antibiotics may be administered for 4—7 days even after the symptoms have improved after antibiotic therapy in patients with delayed drug response [ ].

Second-line therapy should be considered when patients' symptoms worsen within 72 hours of initial empirical therapy or when patients show no improvement even after 3—5 days of treatment. Reassess the patient based on imaging, microbial cultures, and antibiotic susceptibility tests.

If microbial culture and sensitivity tests for the causative pathogens are difficult, use antibiotics that treat multidrug-resistant S.

Second-line antibiotics to treat acute bacterial rhinosinusitis should be chosen in consideration of the following: prevalence of the causative pathogen of acute bacterial rhinosinusitis in Korea, prevalence of antimicrobial-resistant bacteria in Korea, antibacterial effects against three pathogens of acute bacterial rhinosinusitis i.

If symptoms worsen within 72 hours of beginning the initial treatment or the symptoms do not show improvement even after 3—5 days of beginning treatment, the patient should be reassessed in terms of 1 the accuracy of diagnosis, 2 non-infectious cause, 3 antimicrobial-resistant bacteria, and 4 presence of structural problems. It is best to perform cultures with fine needle aspiration of the sinus, but cultures can be performed using samples taken from the middle nasal meatus via nasal endoscopy [ 94 , ].

Cultures using nasopharyngeal swabs are not recommended [ 94 , ]. If the patient is indeed diagnosed with acute bacterial rhinosinusitis after reassessment, initiate antibiotic therapy for patients who initially had been placed on watchful waiting, and change antibiotics for patients who had been on antibiotic therapy [ 94 , ]. The following must be considered if a second-line regimen must be chosen due to failure of the initial empirical antibiotic therapy.

Cefaclor and cefprozil, a second-generation cephalosporin, are not recommended because the most common pathogens of acute bacterial rhinosinusitis, namely, S. Oral cefditoren and cefcapene and cefpodoxime have been reported to be efficacious for treating acute bacterial rhinosinusitis caused by penicillin-resistant S. Oral cefuroxime and cefdinir are known to be effective for acute bacterial rhinosinusitis caused by moderately penicillin-resistant S.

To widen the microbiologic spectrum to cover anaerobes, additional use of metronidazole or clindamycin is recommended with cephalosporin [ ]. The fluoroquinolones such as levofloxacin, and moxifloxacin may be effective, but the possibility of resistance to these antibiotics among Myocobacterium tuberculosis and S.

It should further be noted that the FDA recommended in that fluoroquinolones be used for sinusitis, bronchitis, and urinary tract infection without complications only when there are no other treatment alternatives [ 1 , 6 , ]. Canadian and British studies have reported that the susceptibility rates of S. Doxycycline may be used as the second-line antibiotic therapy for adults with acute bacterial rhinosinusitis as an alternative to fluoroquinolones when the patient has difficulty receiving or has not responded to the initial empirical antibiotic therapy [ ].

This choice is supported by the pharmacokinetic superiority of doxycycline and the finding that doxycycline and levofloxacin have no differences in clinical outcomes but that doxycycline is associated with lower medical costs in patients admitted to community hospitals with pneumonia [ , ].

Although telithromycin, a ketolide, is known to have antibacterial activity against macrolide-resistant S. IV ceftriaxone and cefotaxime have been found to act on all strains of S. Furthermore, if the prevalent S. Additional tests and surgical treatment may be considered when symptoms worsen without improvement within 48—72 hours after proper antibiotic therapy or when ocular or central nervous system complications are suspected [ ].

Treatment duration is generally 4—7 additional days after the improvement of clinical symptoms, and total treatment duration generally ranges 10—14 days. For patients who show no improvement despite appropriate first- or second-line antimicrobial therapy or patients with recurrent acute sinusitis, additional diagnosis should be performed in consideration of allergic rhinitis, immune abnormalities, and tooth infections.

When a related comorbidity is diagnosed, provide treatment according to the guideline for each morbidity. Consider environmental therapy, immune therapy, and drug therapy for patients with hypersensitivity.

Surgical treatment may be considered when recurrent acute sinusitis is nonresponsive to appropriate drug therapy. In cases where the patient fails to show improvement despite appropriate first- and second-line antibiotic therapy, including antibiotic therapy, and cases defined as recurrent acute sinusitis more than four episodes of sinusitis per year with symptom-free intervals [ ], differential diagnosis in consideration of allergic rhinitis, immune abnormalities, and tooth infections, is recommended.

Surgical treatment may be considered for continual episodes of acute sinusitis [ ]. According to a systematic literature review, allergy tests may be run for recurrent acute sinusitis or chronic sinusitis [ ]. Allergic patients characteristically have obstructions of the natural ostium caused by the edema of the nasal cavity and sinus mucosa.

Particularly, the ethmoid sinus with several natural ostia is susceptible to allergic sinusitis or nasal polyp. If a patient is indeed positive for allergy, environmental therapy, immune therapy, or drug therapy may be considered depending on the patient. However, there is limited evidence supporting that environmental therapy and immune therapy are effective in improving the clinical outcome of recurrent acute sinusitis or chronic sinusitis [ , ].

Asthma is closely related to recurrent acute sinusitis or chronic sinusitis and is the cause of frequent recurrent episodes of sinusitis [ ]. For patients diagnosed with immunodeficiency, such as antibody deficiency, prophylactic antibiotic therapy, pneumococcal vaccination, or regular IV IgG may be considered [ ]. In addition, sinusitis may be induced by dental caries or extraction of maxillary molars and premolars, trauma, malnutrition, prolonged steroid therapy, general weakness as a result of diabetes, and tumor in the nasal cavity or sinus; therefore, the corresponding examinations should be performed when such conditions are suspected.

Cases in which the patient fails to show improvement or has recurrent inflammation despite appropriate treatment require additional tests, such as nasal endoscopy and radiological imaging, and referral to a corresponding specialist. Quality of evidence: Very low, Strength of recommendation: Weak. Patients with suspected orbital or intracranial complications of acute rhinosinusitis should be immediately referred to a specialist.

A lack of improvement or worsening of symptoms even after 3—5 days of antibiotic therapy for acute rhinosinusitis is considered a treatment failure. The exact cause should be identified when the patient is nonresponsive even to the second-line antibiotic regimen as well as in cases of recurrent rhinosinusitis, defined as more than four episodes of acute rhinosinusitis per year with symptom-free intervals [ ].

Potential causes include chronic rhinosinusitis, allergic rhinitis, abnormal anatomical structure within the nasal cavity, reduced immunity, fungal infection, granuloma, and tumor. For accurate differentiation of the cause and administration of appropriate treatment, the patient must be referred to a specialist who can perform nasal endoscopy and, when necessary, imaging tests such as CT and MRI [ ]. Paranasal sinuses are in close proximity to the orbits laterally and to the base of the skull superiorly.

Therefore, an infection in the sinuses may spread to the orbits and cranium, causing fatal diseases such as cellulitis, cerebromeningitis, and abscess [ ]. A lack of proper antibiotic therapy and surgical drainage may lead to blindness, brain injury, and in severe cases, to death [ , ].

Severe ocular pain, periocular edema, oculomotor disability, exophthalmos, purulent conjunctivitis, and reduced visual acuity in patients with acute rhinosinusitis are suggestive of ocular complications whereas high fever, severe headache, meningeal irritation sign, and insanity are suggestive of intracranial complications.

Patients with such conditions must be referred to a specialist immediately [ ]. Despite the high prevalence of acute URI, relevant research with good evidence-based findings is critically lacking.

Furthermore, most clinical trials that were used as the basis of reference for this guideline was conducted abroad, with little research data involving Korean patients, thus requiring clinicians to adequately take note of this limitation when utilizing this guideline in the clinical setting.

Studies involving Korean subjects are essential to accumulate relevant data, to make appropriate revisions to Korean guidelines. First, the causative pathogen of acute URI in Korean adults must be identified. Seasonal variations of viruses and bacteria and their proportions should be investigated to minimize inappropriate use of antibiotics. Second, more data are needed to support appropriate selections of empirical antibiotics based on various patterns of antibiotic susceptibility among bacterial strains isolated from patients with acute bacterial URI.

Third, studies must analyze the effectiveness of rapid antigen tests using pharyngeal swabs and bacterial cultures for Korean adults as well as assessing the usefulness of cultures using sinus-related specimens. In addition, studies should also assess the impact of relevant tests, ASO, C-reactive protein, and procalcitonin tests on the treatment outcome, to lay the foundation for developing a clinically applicable diagnostic flowchart.

Finally, medical professionals' adherence to this guideline should be assessed, to estimate its utilization and analyze factors that hamper adherence so as to make necessary revisions to the guideline in the future. Furthermore, comparing actual antibiotic prescribing patterns and recommendations using HIRA insurance claims data may also provide useful data to help lower inappropriate use of antibiotics for acute upper respiratory infection.

This guideline will be regularly revised to keep abreast of the latest key research findings in Korea and abroad. The guideline development committee declares no conflict of interest with respect to any governmental agency, pharmaceutical company, hospital, or interest group during the process of development of this guideline. Conflict of Interest: No conflicts of interest. Guideline Korean version. National Center for Biotechnology Information , U.

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