What is the first-line treatment for bacterial sinusitis with positive Ear, Nose, and Throat (ENT) physical examination (PE) findings?

From the Guidelines

The first-line treatment for bacterial sinusitis with positive ENT physical examination findings is amoxicillin-clavulanate, typically prescribed at a dose of 45 mg/kg/day divided twice daily for children, as recommended by the American Academy of Pediatrics 1.

Key Considerations

• The treatment should be accompanied by symptomatic measures including saline nasal irrigation, intranasal corticosteroids, and analgesics as needed.
• Amoxicillin-clavulanate is preferred over amoxicillin alone because the addition of clavulanic acid helps overcome beta-lactamase resistance, which is common in bacterial pathogens causing sinusitis such as Haemophilus influenzae, Moraxella catarrhalis, and some strains of Streptococcus pneumoniae.
• Patients should complete the full course of antibiotics even if symptoms improve before completion to prevent recurrence and antibiotic resistance.
• If symptoms worsen after 48-72 hours or fail to improve after 3-5 days of treatment, the patient should be reevaluated for possible treatment adjustment.

Special Considerations

• For children with severe, worsening, or persistent acute bacterial sinusitis, antibiotics should be prescribed, and amoxicillin alone or in combination with clavulanate is the first-line antibiotic choice 1.
• In patients with penicillin allergy, alternatives include cefdinir, cefuroxime, or cefpodoxime 1.
• A single 50-mg/kg dose of ceftriaxone can be used for children who are vomiting, unable to tolerate oral medication, or unlikely to be adherent to the initial doses of antibiotic 1.

From the FDA Drug Label

Acute bacterial sinusitis 500 mg QD × 3 days

The first-line treatment for bacterial sinusitis with positive Ear, Nose, and Throat (ENT) physical examination (PE) findings is azithromycin 500 mg once daily for 3 days 2.

• Key points:
  • Azithromycin is effective against a wide range of bacteria that cause sinusitis.
  • The recommended dose is 500 mg once daily for 3 days.
  • This treatment regimen is suitable for adults with mild to moderate sinusitis.

From the Research

ENT PE Positive Findings for Bacterial Sinusitis

• The first-line treatment for bacterial sinusitis with positive Ear, Nose, and Throat (ENT) physical examination (PE) findings includes antibiotics such as amoxicillin or amoxicillin-clavulanate 3.
• For patients with a beta-lactam allergy, appropriate antibiotics include doxycycline or a respiratory fluoroquinolone; clindamycin plus a third-generation cephalosporin is an option for children with non-type I hypersensitivity to beta-lactam antibiotics 3.
• The duration of treatment for acute sinusitis is typically 10-14 days, but some studies suggest that short-course therapy (less than or equal to 5 days) may be effective 4.
• A study comparing ceftriaxone and amoxicillin-clavulanic acid for the treatment of acute bacterial rhinosinusitis found that ceftriaxone was more effective 5.
• Supportive care for rhinosinusitis, including use of saline irrigation, nasal steroids or antihistamines, and decongestants, may help reduce the severity of symptoms 3.

Treatment Options

• Amoxicillin is as effective as amoxicillin-clavulanate as a first-line treatment for acute bacterial rhinosinusitis for those without a beta-lactam allergy 3.
• Doxycycline or a respiratory fluoroquinolone may be used as an alternative for patients with a beta-lactam allergy 3.
• Ceftriaxone may be considered as a treatment option for acute bacterial rhinosinusitis, particularly for patients who do not respond to amoxicillin-clavulanic acid 5.

Diagnosis and Management

• Acute bacterial rhinosinusitis is a clinical diagnosis, and the challenge lies in distinguishing between the symptoms of bacterial and viral sinusitis 3.
• Cardinal features of acute bacterial rhinosinusitis include unilateral facial pain or pressure, fever greater than 102°F (39°C), and purulent nasal discharge with obstruction of the nasal passages 3.
• 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 3.