From the Guidelines
For patients with chronic sinusitis who are allergic to penicillin, doxycycline is often a suitable first-line antibiotic choice. The typical regimen is doxycycline 100 mg twice daily for 10-14 days 1. Alternatives include clarithromycin 500 mg twice daily, azithromycin 500 mg on day one followed by 250 mg daily for 4 days, or levofloxacin 500 mg daily for 10-14 days 1. The choice depends on the severity of the penicillin allergy, local resistance patterns, and patient-specific factors. Doxycycline is particularly effective because it covers common sinusitis pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. For patients with severe penicillin allergies (anaphylaxis), fluoroquinolones like levofloxacin may be preferred, though they carry more significant side effects and resistance concerns 1.
Key Considerations
- Patients should complete the full course of antibiotics even if symptoms improve earlier
- Staying well-hydrated is crucial
- Saline nasal irrigation can be considered as an adjunct therapy to improve mucus clearance and reduce inflammation 1
- In cases of chronic non-infectious sinusitis, consideration should be given to systemic corticosteroids 1
- Evaluation should include coronal sinus CT with extra cuts through the ostiomeatal complex to clarify the extent of disease and specific location or locations 1
Additional Therapy
- Intranasal corticosteroids as an adjunct to antibiotic therapy might be helpful in treating recurrent acute and chronic sinusitis 1
- Other adjunctive therapy, such as antihistamines, decongestants, mucolytics, and expectorants, might provide symptomatic benefit in selected cases 1
From the FDA Drug Label
Acute bacterial sinusitis 500 mg QD × 3 days The antibiotic azithromycin is suitable for a patient with chronic sinusitis who is allergic to penicillin (PCN), the recommended dose is 500 mg once daily for 3 days 2.
From the Research
Antibiotic Options for Chronic Sinusitis in Penicillin-Allergic Patients
- For patients with chronic sinusitis who are allergic to penicillin, alternative antibiotics can be considered 3.
- Macrolide antibiotics, such as clarithromycin or azithromycin, may be prescribed for patients with serious drug allergies 3.
- Other options include cefuroxime, cefpodoxime, or cefdinir, which can be used in patients who are unresponsive to amoxicillin or have a penicillin allergy 3.
Treatment Approaches for Chronic Sinusitis
- Daily high-volume saline irrigation with topical corticosteroid therapy is recommended as a first-line therapy for chronic sinusitis 4.
- A short course of systemic corticosteroids, a short course of doxycycline, or a leukotriene antagonist may be considered in patients with nasal polyps 4.
- A prolonged course of macrolide antibiotic may be considered for patients without polyps 4.
Management of Chronic Rhinosinusitis
- Corticosteroid nasal irrigations have been shown to be more effective than simple sprays in controlling symptoms and signs of chronic rhinosinusitis after sinus surgery 5.
- Dietary salicylate avoidance and leukotriene-modifying drugs are options for treatment, following appropriate treatment with nasal corticosteroids and saline irrigation 6.
- Desensitization with daily aspirin therapy is recommended following revision endoscopic sinus surgery (ESS) 6.