From the Guidelines
Acute sinusitis treatment should prioritize symptom management with nasal saline irrigation, over-the-counter pain relievers, and intranasal corticosteroids, reserving antibiotics for persistent or severe cases. For most cases of acute sinusitis, start with nasal saline irrigation and over-the-counter pain relievers like acetaminophen (Tylenol) 500-1000mg every 6 hours or ibuprofen (Advil, Motrin) 400-600mg every 6-8 hours as needed for pain and inflammation 1. Intranasal corticosteroids such as fluticasone (Flonase) 1-2 sprays per nostril daily or mometasone (Nasonex) can reduce inflammation and improve drainage. Decongestants like pseudoephedrine (Sudafed) 30-60mg every 4-6 hours may help temporarily but shouldn't be used for more than 3 days to avoid rebound congestion.
Key Considerations
- Most cases of acute sinusitis are viral and resolve within 7-10 days without antibiotics 1.
- If symptoms persist beyond 10 days, worsen after initial improvement, or include high fever, severe facial pain, and purulent nasal discharge, bacterial sinusitis may be present 1.
- In cases of bacterial sinusitis, amoxicillin 500mg three times daily for 5-7 days is typically the first-line antibiotic, with amoxicillin-clavulanate 875/125mg twice daily for 5-7 days used for more severe cases or those with risk factors for resistant bacteria 1.
- Staying hydrated, using a humidifier, and avoiding irritants like cigarette smoke can also help speed recovery by keeping mucus thin and promoting drainage.
Adjunctive Therapies
- Analgesics may be offered for pain, and antipyretics may be offered for fever 1.
- Additional therapies that may provide symptomatic relief include systemic or topical decongestants, saline nasal irrigation, mucolytics, intranasal corticosteroids, and antihistamines tailored to the patient's symptoms 1.
From the FDA Drug Label
Acute bacterial sinusitis 500 mg QD × 3 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 an open label, noncomparative study requiring baseline transantral sinus punctures the following outcomes were the clinical success rates at the Day 7 and Day 28 visits for the modified intent to treat patients administered 500 mg of azithromycin once daily for 3 days with the following pathogens: S. pneumoniae 23/26 (88%) 21/25 (84%) H influenzae 28/32 (87%) 24/32 (75%) M. catarrhalis 14/15 (93%) 13/15 (87%)
The recommended treatment for acute bacterial sinusitis is azithromycin 500 mg once daily for 3 days 2. The clinical cure rate for this treatment was 88% at Day 10 and 71.5% at Day 28, compared to 85% at Day 10 and 71.5% at Day 28 for amoxicillin/clavulanate 500/125 mg tid for 10 days 2.
- Key pathogens and their corresponding clinical success rates at Day 7 and Day 28 are:
- S. pneumoniae: 88% and 84%
- H. influenzae: 87% and 75%
- M. catarrhalis: 93% and 87% The most common side effects were diarrhea, nausea, and abdominal pain 2.
From the Research
Treatment Options for Acute Sinusitis
- Antibiotics:
- Dosage and Duration:
- High-dose amoxicillin plus clavulanate may not be more effective than standard-dose amoxicillin plus clavulanate 3
- Amoxicillin and clavulanate given every 12 hours is as effective and safe as administration every 8 hours 5
- A 3-day course of azithromycin can be as effective as a 10-day course of amoxicillin/clavulanate 6
- A single 2-g dose of azithromycin extended release can provide symptom resolution similar to 10 days of amoxicillin/clavulanate 7
Efficacy and Safety
- Clinical success rates for amoxicillin plus clavulanate and azithromycin are similar, with around 90-95% of patients achieving clinical success 5, 6
- Adverse events related to treatment are reported with similar frequency in different treatment groups 3, 5, 6
- Azithromycin has been shown to have a faster clinical effect and simpler dosage regimen compared to amoxicillin/clavulanate 6, 7