From the Guidelines
For patients with acute bacterial rhinosinusitis who are allergic to penicillin, folate inhibitors such as trimethoprim-sulfamethoxazole are a recommended alternative, as they are cost-effective and have a narrow microbiological spectrum 1. When considering alternative antibiotics for patients with acute bacterial rhinosinusitis who are allergic to penicillin, it is essential to weigh the benefits and risks of each option.
- The macrolide class of antibiotics may also be used for patients with penicillin allergy, as stated in the clinical practice guideline on adult sinusitis 1.
- However, the choice of antibiotic should be based on factors such as local resistance patterns, patient-specific factors, and the severity of the infection.
- It is crucial to counsel patients on the use of the medication, potential adverse effects, and the importance of adherence with dosing schedules, as well as consider the out-of-pocket expense of antibiotics, which could represent a potential barrier to having the prescription filled and used as directed 1.
- Symptomatic measures like hydration, analgesics, and other supportive therapies should also be highlighted to aid patients in understanding symptomatology and defining realistic expectations concerning treatment 1.
From the FDA Drug Label
Acute Bacterial Sinusitis In a randomized, double blind, double-dummy controlled clinical trial of acute bacterial sinusitis, azithromycin (500 mg once daily for 3 days) was compared with amoxicillin/clavulanate (500/125 mg tid for 10 days).
For the 594 patients analyzed in the modified intent to treat analysis at the Day 10 visit, the clinical cure rate for 3 days of azithromycin was 88% (268/303) compared to 85% (248/291) for 10 days of amoxicillin/clavulanate.
In an open label, noncomparative study requiring baseline transantral sinus punctures the following outcomes were the clinical success rates at the Day 7 and Day 28 visits for the modified intent to treat patients administered 500 mg of azithromycin once daily for 3 days with the following pathogens:
PathogenAzithromycin (500 mg per day for 3 Days) Day 7Day 28 S. pneumoniae23/26 (88%)21/25 (84%) H influenzae28/32 (87%)24/32 (75%) M. catarrhalis14/15 (93%)13/15 (87%)
- Alternative antibiotics for acute bacterial rhinosinusitis in patients allergic to penicillin include:
- Azithromycin
- Levofloxacin
- Key points:
From the Research
Alternatives to Penicillin for Acute Bacterial Rhinosinusitis
In cases where patients are allergic to penicillin, several alternative antibiotics can be prescribed for the treatment of acute bacterial rhinosinusitis. These alternatives include:
- Cefuroxime, cefpodoxime, or cefdinir, as suggested by 4 and 5
- Clarithromycin or azithromycin, which may be prescribed in cases of serious drug allergy, as mentioned in 4 and studied in 6 and 7
- Doxycycline or a respiratory fluoroquinolone, as recommended by 8 for patients with a beta-lactam allergy
Considerations for Antibiotic Selection
When selecting an alternative antibiotic, it is essential to consider the patient's specific allergy and the potential for cross-reactivity with penicillins. As noted in 5, most cephalosporins are unlikely to be associated with cross-reactivity with penicillins and may be effective alternatives.
Efficacy of Alternative Antibiotics
Studies have shown that clarithromycin and amoxicillin/clavulanate are equally effective in treating acute rhinosinusitis, with clarithromycin patients experiencing rapid improvement in symptoms 6. Additionally, clarithromycin and azithromycin have been found to have adequate penetration into sinus fluid to eradicate erythromycin-sensitive strains of Streptococcus pneumoniae 7.