What is the first-line treatment for bacterial sinusitis?

From the Guidelines

The best sinus infection medication is amoxicillin or amoxicillin-clavulanate, which should be prescribed for 5 to 10 days for most adults. For adults, the typical dosage is amoxicillin 500-875 mg orally three times daily, or amoxicillin-clavulanate 875/125 mg twice daily. Treatment should be accompanied by symptomatic relief measures such as:

• Saline nasal irrigation
• Analgesics for pain
• Decongestants if needed Antibiotics are recommended when symptoms are severe, persist beyond 10 days, or worsen after initial improvement. These antibiotics are preferred because they effectively target the most common bacterial pathogens in sinusitis, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1. If a patient has a penicillin allergy, alternatives include doxycycline, trimethoprim-sulfamethoxazole, or a respiratory fluoroquinolone. Patients should complete the full course of antibiotics even if symptoms improve before completion to prevent recurrence and antibiotic resistance.

The choice of antibiotic is based on randomized controlled trials with heterogeneity and noninferiority design with a preponderance of benefit over harm 1. It's essential to note that acute uncomplicated rhinosinusitis is a self-limited infection that usually resolves without antibiotics, even in patients with a bacterial cause 1. However, antibiotics are necessary when symptoms persist or worsen, and amoxicillin or amoxicillin-clavulanate is the preferred first-line treatment.

In addition to antibiotics, adjunctive therapy such as intranasal saline irrigation or intranasal corticosteroids has been shown to alleviate symptoms and potentially decrease antibiotic use 1. Patients who are seriously ill, who deteriorate clinically despite antibiotic therapy, or who have recurrent episodes should be referred to a specialist. 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.

Overall, the treatment of bacterial sinusitis should be guided by clinical signs and symptoms, and antibiotics should be reserved for patients with persistent or severe symptoms. Amoxicillin or amoxicillin-clavulanate is the recommended first-line treatment, and patients should complete the full course of antibiotics to prevent recurrence and antibiotic resistance 1.

From the FDA Drug Label

1.4 Acute Bacterial Sinusitis: 5 Day and 10 to 14 Day Treatment Regimens Levofloxacin tablets are indicated for the treatment of acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis [see Clinical Studies (14.4)].

The first-line treatment for bacterial sinusitis is levofloxacin.

• Levofloxacin is indicated for the treatment of acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.
• The recommended treatment regimens are 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days 2.

From the Research

Treatment Options for Bacterial Sinusitis

• The first-line treatment for bacterial sinusitis typically involves antibiotics, with the goal of targeting the most common bacterial pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 3.
• High-dose amoxicillin or amoxicillin-clavulanate are often recommended as initial therapies, with alternatives such as cefuroxime, cefpodoxime, or cefdinir considered in cases of penicillin allergy or unresponsiveness to amoxicillin 3.
• For patients with serious drug allergies, clarithromycin or azithromycin may be prescribed as alternative options 3.

Antibiotic Resistance and Treatment

• The increasing prevalence of antimicrobial resistance among S. pneumoniae and beta-lactamase production among H. influenzae poses a significant challenge to effective treatment 4, 5.
• Amoxicillin-clavulanate has been shown to be effective against penicillin-resistant S. pneumoniae and beta-lactamase-producing pathogens, making it a valuable treatment option 4, 5, 6.
• New formulations of amoxicillin-clavulanate, such as extended-release tablets, have been developed to enhance efficacy and coverage of resistant pathogens 4, 6.

Comparative Effectiveness of Antibiotics

• Studies have compared the effectiveness of different antibiotics, including cefdinir and amoxicillin-clavulanate, in the treatment of acute community-acquired bacterial sinusitis 7.
• Cefdinir has been shown to be as effective as amoxicillin-clavulanate in clinical and microbiologic outcomes, with similar rates of adverse events 7.