From the Guidelines
Amoxicillin-clavulanate is the preferred antibiotic of choice for sinusitis, especially in patients with risk factors for drug-resistant pathogens, as it effectively targets Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, and overcomes beta-lactamase producing organisms. The recommended adult dosage is 875/125 mg twice daily for 5-10 days, with children receiving 45-90 mg/kg/day divided into two doses. For patients without risk factors, amoxicillin may be considered as an alternative, with a recommended dosage of 500 mg three times daily or 875 mg twice daily for 5-10 days. In penicillin-allergic patients, alternatives include doxycycline (100 mg twice daily), levofloxacin (500 mg daily), or moxifloxacin (400 mg daily) 1. It's essential to note that most cases of sinusitis are viral and resolve without antibiotics within 7-10 days, so antibiotics should be reserved for patients with symptoms lasting more than 10 days, severe symptoms, or worsening symptoms after initial improvement.
Some key points to consider when treating sinusitis include:
- The American Academy of Otolaryngology–Head and Neck Surgery emphasizes watchful waiting (without antibiotic therapy) as initial management for all patients with uncomplicated acute bacterial rhinosinusitis (ABRS), regardless of severity 1.
- The American Academy of Pediatrics recommends amoxicillin as the first-line empirical therapy for acute bacterial sinusitis in children, with amoxicillin-clavulanate as an alternative for patients with risk factors for drug-resistant pathogens 1.
- The Infectious Diseases Society of America recommends amoxicillin-clavulanate as the initial empirical antimicrobial therapy for acute bacterial sinusitis in children and adults, due to the increasing prevalence of H influenzae and beta-lactamase production among these strains 1.
Overall, the choice of antibiotic for sinusitis should be based on the patient's individual risk factors, symptoms, and medical history, and should always prioritize the use of narrow-spectrum antibiotics to minimize the risk of antibiotic resistance and promote high-value care 1.
From the FDA Drug Label
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 antibiotic of choice for sinusitis is levofloxacin, which can be administered as a 5-day or 10-14 day treatment regimen.
- The 5-day regimen consists of 750 mg by mouth once daily.
- The 10-14 day regimen consists of 500 mg by mouth once daily. Clinical success rates for the treatment of acute bacterial sinusitis with levofloxacin are 91.4% for the 5-day regimen and 88.6% for the 10-day regimen 2.
From the Research
Antibiotic of Choice for Sinusitis
The antibiotic of choice for sinusitis depends on various factors, including the severity of symptoms, patient age, and potential allergies.
- For adults, high-dose amoxicillin or amoxicillin-clavulanate is recommended as the first-line treatment 3.
- In cases of penicillin allergy or unresponsiveness to amoxicillin, alternatives such as cefuroxime, cefpodoxime, or cefdinir may be prescribed 3.
- For children, amoxicillin-clavulanate at a standard dose of 45 mg/kg/day orally is considered the drug of choice for most cases of uncomplicated acute bacterial sinusitis 4.
- In severe cases or when antibiotic resistance is suspected, oral high-dose amoxicillin-clavulanate (90 mg/kg/day) may be prescribed 4.
Alternative Treatment Options
- Cefdinir has been shown to be effective in treating acute community-acquired bacterial sinusitis, with a similar cure rate to amoxicillin-clavulanate 5.
- Macrolides, such as clarithromycin or azithromycin, may be prescribed in cases of serious drug allergy 3.
- Doxycycline, levofloxacin, or moxifloxacin may be considered as second-line treatments 6.
Guideline Concordance and Antibiotic Stewardship
- Studies have shown that there is still room for improvement in antibiotic prescribing practices for acute sinusitis, particularly in rural areas and urgent care settings 6.
- Otolaryngologists are more likely to engage in watchful waiting and prescribe recommended first-line antibiotic therapy, such as amoxicillin-clavulanate, compared to non-otolaryngologists 7.