What is the best treatment for sinus infection in a patient with allergies to doxycycline (Doxy), penicillin (PCN), and cephalosporins?

From the Guidelines

For a sinus infection in someone allergic to doxycycline, penicillins, and cephalosporins, the best antibiotic option would be a fluoroquinolone such as levofloxacin or a macrolide like azithromycin, with levofloxacin being a preferred choice due to its excellent coverage against common sinus pathogens, as noted in the study published in the Journal of Allergy and Clinical Immunology 1. When considering treatment options, it's essential to weigh the potential benefits and risks of each antibiotic. Fluoroquinolones, such as levofloxacin, offer broad-spectrum coverage against common sinus pathogens, including Streptococcus pneumoniae and Haemophilus influenzae, making them a suitable choice for patients with allergies to other antibiotics 1. Some key points to consider when prescribing levofloxacin include:

• Dosage: typically 500mg once daily for 5-7 days
• Coverage: excellent against common sinus pathogens, including S. pneumoniae and H. influenzae
• Safety: generally well-tolerated, but may cause adverse effects such as nausea, diarrhea, and headache In contrast, macrolides like azithromycin may not provide adequate coverage against certain bacteria, such as penicillin-resistant S. pneumoniae, which could lead to treatment failure 1. Additionally, patients should be advised to:
• Use saline nasal irrigation 2-3 times daily to help loosen mucus
• Take over-the-counter pain relievers and nasal decongestants as needed, but limited to 3 days to prevent rebound congestion
• Practice steam inhalation and adequate hydration to help thin mucus
• Monitor their symptoms and seek medical attention if they worsen or persist beyond 7-10 days, as this may indicate the need for antibiotic therapy or further evaluation.

From the FDA Drug Label

In a controlled double-blind study conducted in the U.S., moxifloxacin hydrochloride tablets (400 mg once daily for ten days) were compared with cefuroxime axetil (250 mg twice daily for ten days) for the treatment of acute bacterial sinusitis. Clinical success (cure plus improvement) at the 7 to 21 day post-therapy test of cure visit was 90% for moxifloxacin hydrochloride and 89% for cefuroxime. An additional non-comparative study was conducted to gather bacteriological data and to evaluate microbiological eradication in adult patients treated with moxifloxacin 400 mg once daily for seven days All patients (n = 336) underwent antral puncture in this study. Clinical success rates and eradication/presumed eradication rates at the 21 to 37 day follow-up visit were 97% (29 out of 30) for Streptococcus pneumoniae, 83% (15 out of 18) for Moraxella catarrhalis, and 80% (24 out of 30) for Haemophilus influenzae.

Moxifloxacin is a potential option for the treatment of sinus infections in patients allergic to doxycycline, penicillin, and cephalosporins, with clinical success rates of 90% in one study and eradication rates of 97% for Streptococcus pneumoniae, 83% for Moraxella catarrhalis, and 80% for Haemophilus influenzae in another study 2.

• Key pathogens: Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae
• Clinical success rates: 90%
• Eradication rates: 97% for Streptococcus pneumoniae, 83% for Moraxella catarrhalis, 80% for Haemophilus influenzae

Alternatively, levofloxacin may also be considered, with clinical success rates of 91.4% in one study and eradication rates of 95% for multi-drug resistant Streptococcus pneumoniae in another study 3.

• Key pathogens: multi-drug resistant Streptococcus pneumoniae
• Clinical success rates: 91.4%
• Eradication rates: 95% for multi-drug resistant Streptococcus pneumoniae

From the Research

Alternatives to Doxy, PCN, and Cephalosporins for Sinus Infection

• For patients allergic to doxy, PCN, and cephalosporins, alternative antibiotics can be considered for the treatment of sinus infections 4.
• Azithromycin is a potential option, as it has been shown to be effective in the treatment of acute sinusitis, with a simpler dosage regimen and faster clinical effect compared to amoxicillin/clavulanate 5, 6.
• Clarithromycin may also be prescribed in cases of serious drug allergy 4.
• Macrolide antibiotics, such as clarithromycin and azithromycin, have immunomodulatory properties that can be beneficial in the management of chronic rhinosinusitis 7.

Considerations for Penicillin Allergy

• Many patients report allergies to penicillin, but clinically significant IgE-mediated or T lymphocyte-mediated penicillin hypersensitivity is uncommon (<5%) 8.
• Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2% of cases 8.
• Patients with a low-risk history of penicillin allergy can be evaluated with direct amoxicillin challenge, while moderate-risk patients can be evaluated with penicillin skin testing 8.

Treatment Duration and Efficacy

• The optimal duration of therapy for sinus infections is unknown, but treatment until the patient becomes free of symptoms and then for an additional 7 days is recommended 4.
• Azithromycin has been shown to be effective in the treatment of acute sinusitis, with cure rates of 95% and 98% at the end of therapy and follow-up visit, respectively 5.
• Bacteriologic eradication was achieved in 23 of 23 and 21 of 24 patients treated with azithromycin and amoxicillin/clavulanate, respectively 5.