What is the treatment for acute sinusitis?

From the Guidelines

For acute sinusitis treatment, supportive care is recommended as the initial management, reserving antibiotic treatment for patients with persistent or severe symptoms. The treatment approach should prioritize supportive care, including analgesics for pain, antipyretics for fever, and additional therapies such as systemic or topical decongestants, saline nasal irrigation, mucolytics, intranasal corticosteroids, and antihistamines tailored to the patient's symptoms 1.

Key Considerations

• Most patients with acute rhinosinusitis have more adverse effects than benefits from antibiotics, with a number needed to treat of 18 for 1 patient to be cured rapidly, but a number needed to harm from adverse effects from antibiotics of 8 1.
• Antibiotic treatment should be reserved for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving 1.
• Adjunctive therapy, such as intranasal saline irrigation or intranasal corticosteroids, has been shown to alleviate symptoms and potentially decrease antibiotic use 1.

Treatment Approach

1. Supportive care: analgesics for pain, antipyretics for fever, and additional therapies such as systemic or topical decongestants, saline nasal irrigation, mucolytics, intranasal corticosteroids, and antihistamines tailored to the patient's symptoms.
2. Antibiotic treatment: reserve for patients with persistent or severe symptoms, using amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days, or doxycycline 100 mg twice daily for penicillin-allergic patients.
3. Nasal corticosteroid spray: fluticasone propionate, 2 sprays in each nostril once daily, to reduce inflammation and swelling.
4. Saline nasal irrigation: use a neti pot or saline spray several times daily to clear mucus and debris. If symptoms don't improve within 7 days or worsen, consult your doctor for possible sinus imaging or culture-directed therapy. This regimen targets both the infection and inflammation, promoting faster recovery and symptom relief.

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

• The treatment for acute sinusitis is levofloxacin 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days 2
• The clinical success rates for levofloxacin 750 mg and 500 mg groups were 91.4% and 88.6%, respectively 2

From the Research

Treatment for Acute Sinusitis

The treatment for acute sinusitis typically involves the use of antibiotics, with the goal of shortening the duration of infection and illness, and preventing complications.

• The recommended first-line therapy for acute sinusitis is amoxicillin with or without clavulanate, as stated in current otolaryngology and other gold standard guidelines 3.
• Amoxicillin-clavulanate is the most common antibiotic prescribed for acute sinusitis, particularly at otolaryngologist visits 3.
• Other antibiotics that may be used to treat acute sinusitis include cefdinir, cefpodoxime proxetil, and cefuroxime axetil, which are effective against Streptococcus pneumoniae, a common pathogen in acute bacterial rhinosinusitis 4.
• For patients who are allergic to amoxicillin, second- or third-generation oral cephalosporins may be used as first-line therapy, or clarithromycin may be considered as an alternative 4.
• High-dose amoxicillin-clavulanate may be recommended for high-risk patients, such as those in day care or who have recently received antibiotics, who show no improvement after treatment with the usual dose of amoxicillin 4.

Antibiotic Selection and Resistance

The selection of antibiotics for acute sinusitis should take into account the potential for resistance, particularly among Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

• Amoxicillin-clavulanate has a broad spectrum of antibacterial activity and a favorable pharmacokinetic/pharmacodynamic profile, making it an effective treatment for acute sinusitis 5.
• However, the emergence of S. pneumoniae strains with elevated penicillin MICs has been observed in certain geographical areas, highlighting the need for alternative treatments 5.
• The use of fluoroquinolones, such as levofloxacin, may be considered for patients with acute sinusitis who have failed first-line therapy or have a history of penicillin allergy, but their use should be guided by local resistance patterns and treatment guidelines 6.

Guideline Recommendations

Guideline recommendations for the treatment of acute sinusitis emphasize the importance of using first-line antibiotics, such as amoxicillin-clavulanate, and reserving broader-spectrum antibiotics for patients who have failed first-line therapy or have a history of penicillin allergy.

• The use of penicillin allergy labels may contribute to the overuse of broader-spectrum antibiotics, highlighting the need for efforts to de-label patients with penicillin allergies and promote the use of first-line antibiotics 7.
• The FDA boxed warning against the use of fluoroquinolones for uncomplicated urinary tract infection, acute sinusitis, and acute bronchitis has not been associated with a significant reduction in fluoroquinolone prescription rates, highlighting the need for additional research and education on antibiotic stewardship 6.