What are the treatment options for Sinusitis?

From the Guidelines

For the treatment of sinusitis, the most effective approach is to use antibiotics such as amoxicillin or amoxicillin-clavulanate for bacterial sinusitis, while also utilizing home remedies like saline nasal irrigation and over-the-counter pain relievers to alleviate symptoms. The choice of antibiotic should be based on the severity of the illness, the patient's age, and the presence of any risk factors for resistance 1.

Key Considerations

• For mild to moderate sinusitis, over-the-counter pain relievers like acetaminophen or ibuprofen can help reduce pain and inflammation.
• Saline nasal irrigation using a neti pot or squeeze bottle with distilled water and saline solution can help flush out mucus and irritants.
• Decongestants such as pseudoephedrine can provide temporary relief by reducing swelling in nasal passages, but should not be used for more than 3 days to avoid rebound congestion.
• Intranasal corticosteroids like fluticasone or mometasone can reduce inflammation and can be used daily for up to several weeks.

Antibiotic Treatment

• Amoxicillin alone or in combination with clavulanate is the first-line antibiotic choice for bacterial sinusitis 1.
• The dosage of amoxicillin can vary depending on the severity of the illness and the patient's age, with a standard dose of 45 mg/kg per day in 2 divided doses for mild to moderate illness, and a high-dose of 80-90 mg/kg per day in 2 divided doses for more severe illness or in areas with a high prevalence of nonsusceptible S pneumoniae 1.
• For patients who are vomiting, unable to take oral medication, or unlikely to be adherent to the initial doses of antibiotic, a single 50-mg/kg dose of ceftriaxone can be used, with the option to switch to oral therapy after clinical improvement 1.

Chronic Rhinosinusitis

• For chronic rhinosinusitis (CRS), clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief 1.
• These treatments can help alleviate symptoms and improve quality of life for patients with CRS.

Important Notes

• The treatment of sinusitis should be individualized based on the patient's specific needs and circumstances.
• It is essential to consider the potential risks and benefits of antibiotic treatment, as well as the possibility of antibiotic resistance.
• Patients should be educated on the importance of completing the full course of antibiotic treatment, even if symptoms improve before the end of the treatment period.

From the FDA Drug Label

For more severe infections and infections of the respiratory tract, the dose should be one 875 mg/125 mg amoxicillin and clavulanate potassium tablet every 12 hours or one 500 mg/125 mg amoxicillin and clavulanate potassium tablet every 8 hours. Table 1: Dosing in Patients Aged 12 weeks (3 months) and Older INFECTIONDOSING REGIMEN Every 12 hours 200 mg/5 mL or 400 mg/5 mL oral suspension a Otitis media b, sinusitis, lower respiratory tract infections, and more severe infections 45 mg/kg/day every 12 hours

The treatment for sinusitis with amoxicillin-clavulanate (PO) is:

• For patients aged 12 weeks (3 months) and older: 45 mg/kg/day every 12 hours or 40 mg/kg/day every 8 hours for more severe infections, using 200 mg/5 mL or 400 mg/5 mL oral suspension.
• For adults: one 875 mg/125 mg amoxicillin and clavulanate potassium tablet every 12 hours or one 500 mg/125 mg amoxicillin and clavulanate potassium tablet every 8 hours for more severe infections 2.

From the Research

Treatment Options for Sinusitis

• Antibiotic therapy should be considered in patients with prolonged or more severe symptoms of acute bacterial rhinosinusitis, with narrow-spectrum antibiotics such as amoxicillin used for 10 to 14 days 3
• In patients with mild disease who have beta-lactam allergy, trimethoprim/sulfamethoxazole or doxycycline are options, while second-line antibiotics should be considered if the patient has moderate disease, recent antibiotic use, or no response to treatment within 72 hours 3
• Amoxicillin-clavulanate potassium and fluoroquinolones have the best coverage for Haemophilus influenzae and Streptococcus pneumoniae, and should be prescribed in patients with beta-lactam hypersensitivity who have moderate disease 3

Supportive Care for Rhinosinusitis

• Decongestants are often recommended, and there is some evidence to support their use, although topical decongestants should not be used for more than three days to avoid rebound congestion 3
• Nasal irrigation with hypertonic and normal saline has been beneficial in chronic sinusitis and has no serious adverse effects 3
• Nasal corticosteroids may be beneficial in treating chronic sinusitis, and also offer a small therapeutic benefit in acute sinusitis, which may be greater with high doses and with courses of 21 days' duration 4
• Saline irrigation, nasal steroids or antihistamines, and decongestants may help reduce the severity of symptoms in rhinosinusitis 5

Diagnostic Testing and Complications

• Diagnostic testing for acute rhinosinusitis with antral puncture is impractical due to its invasiveness, and point-of-care testing for elevated C-reactive protein may be helpful but is not widely available 5
• Complications of rhinosinusitis are rare but may include orbital cellulitis, meningitis, and abscess, and computed tomography and referral to an otolaryngologist should be considered for patients with recurrent rhinosinusitis or concern about complications 5

Antimicrobial Nasal Washes

• Topical antimicrobial nasal irrigations are commonly used for treatment of chronic rhinosinusitis, but there is great variation in methodology and limited scientific support for current treatment formulations 6
• Antimicrobial nasal washes provide a potentially effective treatment for patients who remain symptomatic after appropriate medical and surgical intervention, and evidence-based recommendations for agent selection, concentration, length of treatment, and dosing schedule are needed 6

Adjunctive Therapy with Intranasal Corticosteroids

• The addition of intranasal corticosteroids as an adjunct to antibiotic therapy may be effective in global evaluations, and tends to improve symptoms, decrease inflammatory cells in nasal cytograms, and aid regression of radiographic abnormalities compared with placebo spray 7