From the Guidelines
For a patient with sinusitis who is allergic to both clarithromycin and amoxicillin, cefpodoxime or cefdinir are suitable alternative antibiotic choices. These third-generation cephalosporins can be given orally once or twice daily, as stated in the study by 1. The recommended dosage for cefpodoxime is typically 200 mg twice daily for 10-14 days, while cefdinir is usually prescribed at 300 mg twice daily for 10-14 days. It's essential to note that cefixime and ceftibuten, also third-generation cephalosporins, have poor activity against S pneumoniae and should be avoided for acute bacterial sinusitis, as mentioned in the study by 1.
When prescribing antibiotics for sinusitis, it's crucial to determine if the infection is likely bacterial rather than viral, as most cases of sinusitis are viral and resolve without antibiotics. Bacterial sinusitis is more likely if symptoms persist beyond 10 days, are severe with high fever and purulent discharge, or worsen after initial improvement. Supportive measures like saline nasal irrigation, intranasal corticosteroids, and adequate hydration should accompany antibiotic therapy to help relieve symptoms and improve drainage.
Some key points to consider when treating sinusitis include:
- The appropriate duration of antibiotic therapy is not well defined, but a 10- to 14-day course might be adequate for most patients with acute disease, as suggested by 1.
- If there is no clinical improvement within 3 days of initiating antimicrobial therapy, an alternative antibiotic should be considered, according to 1.
- In protracted or severe cases of sinusitis, the possibility of anaerobic pathogens should be considered, and clindamycin or metronidazole might be considered in combination therapy with a broad-spectrum drug, as stated in the study by 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). The primary endpoint of this trial was prospectively defined as the clinical cure rate at Day 28 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 the safety analysis of this study, the overall incidence of treatment-related adverse events, primarily gastrointestinal, was lower in the azithromycin treatment arm (31%) than in the amoxicillin/clavulanate arm (51%).
For a patient who is allergic to Clarithromycin and amoxicillin, azithromycin can be considered as an alternative for the treatment of sinusitis. The recommended dose is 500 mg once daily for 3 days.
From the Research
Alternative Antibiotics for Sinusitis
Given the patient's allergy to Clarithromycin and Amoxicillin, alternative antibiotics must be considered for the treatment of sinusitis.
- Cefdinir is an option, as it has been shown to be effective in treating acute community-acquired bacterial sinusitis (ACABS) with a cure rate of approximately 90% 2, 3, 4.
- Azithromycin is another alternative, which has been compared to Amoxicillin/Clavulanate in the treatment of acute sinusitis, showing a faster resolution of signs and symptoms and a simpler dosage regimen 5.
Efficacy and Safety of Alternative Antibiotics
The efficacy and safety of Cefdinir and Azithromycin have been evaluated in several studies:
- Cefdinir has been shown to be as effective as Amoxicillin-Clavulanate in treating ACABS, with similar microbiologic eradication rates and fewer adverse events requiring treatment discontinuation 2, 4.
- Azithromycin has been shown to be as effective as Amoxicillin/Clavulanate in treating acute sinusitis, with a significantly faster resolution of signs and symptoms and a simpler dosage regimen 5.
Considerations for Treatment
When considering treatment options for a patient with a history of allergy to Clarithromycin and Amoxicillin, it is essential to evaluate the efficacy and safety of alternative antibiotics, such as Cefdinir and Azithromycin, to determine the best course of treatment 2, 3, 4, 5.