From the Guidelines
For sinusitis in a patient with allergies to macrolides and Augmentin (amoxicillin-clavulanate), I recommend doxycycline 100 mg twice daily for 5-7 days as the first-line alternative treatment. This recommendation is based on the most recent and highest quality study available, which suggests that doxycycline is a suitable alternative for patients with allergies to macrolides and Augmentin 1. If doxycycline is contraindicated, consider levofloxacin 500 mg once daily for 5-7 days, though this should be reserved as a second-line option due to potential side effects.
Key Considerations
- Most cases of acute sinusitis are viral and self-limiting, so antibiotics should be considered only if symptoms persist beyond 10 days, are severe, or worsen after initial improvement 1.
- For symptomatic relief, add saline nasal irrigation 2-3 times daily, intranasal corticosteroids like fluticasone 1-2 sprays per nostril daily, and over-the-counter analgesics such as acetaminophen or ibuprofen as needed for pain and inflammation.
- These recommendations target the common bacterial pathogens in sinusitis (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) while avoiding the allergenic medications.
- If symptoms don't improve within 3-5 days of antibiotic treatment, reevaluation is necessary to consider alternative diagnoses or resistant pathogens 1.
Additional Guidance
- The American Academy of Otolaryngology–Head and Neck Surgery emphasizes watchful waiting (without antibiotic therapy) as initial management for all patients with uncomplicated ABRS, regardless of severity 1.
- Patients who are seriously ill, who deteriorate clinically despite antibiotic therapy, or who have recurrent episodes should be referred to a specialist (for example, an otolaryngologist, infectious disease specialist, or allergist) 1.
From the FDA Drug Label
- 6 Acute Bacterial Sinusitis Moxifloxacin hydrochloride tablets are indicated in adult patients (18 years of age and older) for the treatment of acute bacterial sinusitis (ABS) caused by susceptible isolates of Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis [see CLINICAL STUDIES (14. 1)]. Because fluoroquinolones, including moxifloxacin hydrochloride tablets, have been associated with serious adverse reactions [see WARNINGS AND PRECAUTIONS (5.1 to 5.13)] and for some patients ABS is self-limiting, reserve moxifloxacin hydrochloride tablets for treatment of ABS in patients who have no alternative treatment options.
Treatment for Sinusitis with Allergy to Macrolides and Augmentin: Given the patient's allergy to macrolides and Augmentin, moxifloxacin 2 can be considered as a treatment option for acute bacterial sinusitis, as it is effective against susceptible isolates of Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.
- Key Points:
- Moxifloxacin is indicated for the treatment of acute bacterial sinusitis in adult patients.
- The patient's allergy to macrolides and Augmentin should be taken into consideration when selecting a treatment option.
- Moxifloxacin should be reserved for patients with no alternative treatment options due to the potential for serious adverse reactions.
From the Research
Treatment Options for Sinusitis
Given the allergy to macrolides and Augmentin, the following treatment options can be considered:
- Cefuroxime, cefpodoxime, or cefdinir as alternatives to amoxicillin-clavulanate 3
- Clindamycin and the combination of metronidazole and a penicillin for chronic sinusitis 4
- Cefdinir, which has been shown to be as effective as amoxicillin-clavulanate in treating acute community-acquired bacterial sinusitis 5
Pathogens Involved in Sinusitis
The common pathogens involved in sinusitis include:
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
- Anaerobic bacteria and Staphylococcus aureus in chronic sinusitis 4, 6
Antimicrobial Resistance
Many of the pathogens involved in sinusitis have developed resistance to penicillins, either through the production of beta-lactamase or changes in the penicillin-binding protein 4, 6
- Beta-lactamase-producing bacteria, such as H. influenzae and M. catarrhalis, can survive penicillin therapy and "shield" penicillin-susceptible pathogens from the drug 4
Clinical Effectiveness
Studies have shown that antibiotics can be effective in treating acute bacterial sinusitis, with high-dose amoxicillin or amoxicillin-clavulanate being commonly prescribed 3
- Cefdinir has been shown to be as effective as amoxicillin-clavulanate in treating acute community-acquired bacterial sinusitis, with similar microbiologic eradication rates and fewer adverse events requiring treatment discontinuation 5
- Clarithromycin has been compared to amoxicillin/clavulanate in the treatment of acute maxillary sinusitis, with similar clinical success and bacteriologic cure rates 7