What is the first line treatment for acute sinusitis?

From the Guidelines

The first line treatment for sinusitis is supportive care with analgesics, saline nasal irrigation, and intranasal corticosteroids, with antibiotics reserved for severe, worsening, or persistent cases. According to the most recent and highest quality study 1, most cases of acute rhinosinusitis are self-limited and resolve without antibiotics. The American College of Physicians and the Centers for Disease Control and Prevention recommend reserving antibiotic treatment for patients with persistent symptoms for more than 10 days, worsening symptoms, or severe symptoms such as high fever, facial pain, or purulent discharge.

Some key points to consider in the management of sinusitis include:

• Supportive care with analgesics (such as acetaminophen or ibuprofen) for pain relief, saline nasal irrigation, and intranasal corticosteroids (such as fluticasone 1-2 sprays per nostril daily or mometasone 2 sprays per nostril daily) is the initial treatment of choice.
• Antibiotics are not recommended initially for uncomplicated acute sinusitis as most cases are viral and resolve spontaneously within 7-10 days.
• If symptoms persist beyond 10 days, worsen after initial improvement, or are severe, then antibiotics may be considered.
• The first-line antibiotic is amoxicillin 500mg three times daily or amoxicillin-clavulanate 875/125mg twice daily for 5-7 days, as recommended by 1.
• For penicillin-allergic patients, doxycycline 100mg twice daily or a respiratory fluoroquinolone can be used.
• Decongestants may provide symptomatic relief but should be limited to 3-5 days to avoid rebound congestion.
• Adequate hydration and rest also support recovery.

This approach is recommended because most sinusitis cases are self-limiting viral infections, and unnecessary antibiotic use contributes to antibiotic resistance while exposing patients to potential side effects, as noted in 1.

From the FDA Drug Label

Levofloxacin is approved for the treatment of acute bacterial sinusitis (ABS) using either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days To evaluate the safety and efficacy of a high dose short course of levofloxacin, 780 outpatient adults with clinically and radiologically determined acute bacterial sinusitis were evaluated in a double-blind, randomized, prospective, multicenter study comparing levofloxacin 750 mg by mouth once daily for five days to levofloxacin 500 mg by mouth once daily for 10 days Clinical success rates (defined as complete or partial resolution of the pre-treatment signs and symptoms of ABS to such an extent that no further antibiotic treatment was deemed necessary) in the microbiologically evaluable population were 91.4% (139/152) in the levofloxacin 750 mg group and 88.6% (132/149) in the levofloxacin 500 mg group at the test-of-cure (TOC) visit (95% CI [-4. 2,10] for levofloxacin 750 mg minus levofloxacin 500 mg)

First line treatment of sinusitis can be levofloxacin 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days 2.

• Clinical success rates were 91.4% for the 5-day regimen and 88.6% for the 10-14 day regimen.
• Both regimens are effective for the treatment of acute bacterial sinusitis.

From the Research

First Line Treatment of Sinusitis

• The first line treatment for acute bacterial sinusitis (ABS) typically involves the use of antibiotics, with high-dose amoxicillin or amoxicillin-clavulanate being commonly recommended 3, 4.
• For patients with a penicillin allergy, alternative options such as doxycycline or a respiratory fluoroquinolone may be considered 4.
• The use of supportive care, including saline irrigation, nasal steroids or antihistamines, and decongestants, may also help reduce the severity of symptoms 4.
• Studies have shown that amoxicillin is as effective as amoxicillin-clavulanate as a first-line treatment for acute bacterial rhinosinusitis for those without a beta-lactam allergy 4.

Antibiotic Options

• Amoxicillin-clavulanate is a commonly prescribed antibiotic for ABS, with a 5-day regimen of telithromycin being shown to be noninferior to a 10-day regimen of high-dose amoxicillin-clavulanate in terms of clinical efficacy 5.
• High-dose amoxicillin has been shown to be more effective than standard-dose amoxicillin in achieving rapid improvement in symptoms, although it may also be associated with a higher risk of severe diarrhea 6.
• Other antibiotic options, such as cefuroxime, cefpodoxime, or cefdinir, may be considered in cases where amoxicillin-clavulanate is not suitable 3.

Adherence to Guidelines

• Despite published guidelines recommending amoxicillin with or without clavulanic acid as first-line treatment for ABS, studies have shown that many patients are prescribed alternative antibiotics, such as erythromycins/macrolides, which may not be in line with current recommendations 7.
• Further investigation into the causes of non-adherence to guidelines and education of physicians on current recommendations may be necessary to improve antibiotic stewardship in the treatment of ABS 7.