What is the best treatment for bacterial sinusitis in a patient with impaired renal function (one kidney)?

From the Guidelines

For bacterial sinusitis in a patient with one kidney, amoxicillin-clavulanate (Augmentin) is typically the first-line treatment, usually prescribed at 875/125 mg twice daily for 5-7 days. For patients with penicillin allergies, doxycycline 100 mg twice daily for 5-7 days is a good alternative 1. Since the patient has only one kidney, medication dosing may need adjustment based on their kidney function, which should be assessed using creatinine clearance or eGFR. It's essential to ensure adequate hydration during treatment to support kidney function. Nasal saline irrigation and over-the-counter decongestants can help manage symptoms. If symptoms don't improve within 3-4 days or worsen, the patient should seek follow-up care as they may need a different antibiotic or further evaluation. The single kidney is significant because many antibiotics are eliminated through the kidneys, and without proper dosing adjustments, medication could accumulate to toxic levels or put additional stress on the remaining kidney.

Some key points to consider:

• The diagnosis of bacterial sinusitis is typically based on clinical signs and symptoms, such as persistent symptoms for more than 10 days without clinical improvement, severe symptoms, or worsening symptoms after an initial period of improvement 1.
• Amoxicillin-clavulanate is the preferred agent for empirical antibiotics in patients with acute bacterial rhinosinusitis (ABRS) 1.
• 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.
• For patients with penicillin allergies, doxycycline or a respiratory fluoroquinolone may be used as an alternative 1.
• The treatment of patients with presumed allergy to penicillin has been controversial, but recent publications indicate that the risk of a serious allergic reaction to second- and third-generation cephalosporins in patients with penicillin or amoxicillin allergy appears to be almost nil and no greater than the risk among patients without such allergy 1.

It's crucial to note that the patient's kidney function should be closely monitored during treatment, and adjustments to medication dosing may be necessary to prevent toxicity or additional stress on the remaining kidney.

In terms of the duration of antibiotic therapy, a 10- to 14-day course of antibiotic might be adequate for most patients with acute disease, but some experts suggest that patients should be treated until they are free of symptoms plus 7 days 1. If there is no clinical improvement within 3 days of initiating antimicrobial therapy, an alternative antibiotic should be considered 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 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

The best treatment for bacterial sinusitis for a patient with one kidney is levofloxacin.

• The recommended dose is either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days.
• Clinical success rates for levofloxacin are 91.4% for the 5-day regimen and 88.6% for the 10-14 day regimen. No dosage adjustment is necessary for patients with renal impairment, but caution should be exercised when administering levofloxacin to patients with severe renal impairment 2.

Alternatively, azithromycin can be used to treat acute bacterial sinusitis.

• The recommended dose for adults is 500 mg QD × 3 days.
• No dosage adjustment is recommended for subjects with renal impairment (GFR ≤80 mL/min), but caution should be exercised when azithromycin is administered to subjects with severe renal impairment 3.

From the Research

Treatment Options for Bacterial Sinusitis

• Amoxicillin/clavulanate is a commonly recommended treatment for acute bacterial sinusitis in adults, as stated in 4.
• However, 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, as mentioned in 5.
• A comparative effectiveness study found that amoxicillin demonstrated similar efficacy to amoxicillin-clavulanate for acute sinusitis with fewer gastrointestinal-related adverse events, as reported in 6.

Considerations for Patients with One Kidney

• There is no specific evidence in the provided studies regarding the best treatment for bacterial sinusitis in patients with one kidney.
• However, it is essential to consider the potential risks and benefits of different antibiotic treatments in patients with renal impairment, as some antibiotics may require dose adjustments or have increased toxicity in this population.

Alternative Treatment Options

• Azithromycin extended release has been shown to be effective in treating acute sinusitis, with a single 2-g dose providing similar symptom resolution to 10 days of amoxicillin/clavulanate, as reported in 7.
• Doxycycline or a respiratory fluoroquinolone may be considered as alternative antibiotics for patients with a beta-lactam allergy, as mentioned in 5.