What is the recommended management for bacterial sinusitis in pregnancy?

From the Guidelines

The recommended management for bacterial sinusitis in pregnancy begins with supportive care, including saline nasal irrigation, adequate hydration, and rest, with antibiotics reserved for cases where endoscopic evidence of purulence is present, and penicillin and cephalosporin being the safest classes of antibiotics to use 1. When considering the use of antibiotics, it is crucial to weigh the benefits against the potential risks to the fetus, and to choose antibiotics that are known to be safe during pregnancy.

• The use of oral antibiotics such as penicillin and cephalosporin is recommended for acute rhinosinusitis or acute exacerbations of chronic rhinosinusitis (CRS) when there is evidence of purulence 1.
• Long-term use of macrolide or doxycycline for CRS maintenance is not recommended during pregnancy due to potential fetal risks 1.
• Saline nasal rinses and topical corticosteroid (CCS) nasal sprays are considered suitable maintenance therapy for CRS during pregnancy, prioritizing fetal and maternal safety as well as maternal quality of life 1. Key considerations in the management of bacterial sinusitis in pregnancy include:
• Avoiding the use of antibiotics that are known to pose a risk to the fetus, such as tetracyclines, aminoglycosides, trimethoprim-sulfamethoxazole, and fluoroquinolones 1.
• Monitoring patients closely for resolution of symptoms and adjusting treatment as necessary to minimize the risk of complications and ensure the best possible outcomes for both mother and fetus. Given the potential for serious complications if left untreated, prompt and effective management of bacterial sinusitis in pregnancy is essential, and should be guided by the most recent and highest quality evidence available 1.

From the FDA Drug Label

Pregnancy Category B Reproduction studies have been performed in rats and mice at doses up to moderately maternally toxic dose concentrations (i.e., 200 mg/kg/day). These doses, based on a mg/m2 basis, are estimated to be 4 and 2 times, respectively, the human daily dose of 500 mg. In the animal studies, no evidence of harm to the fetus due to azithromycin was found. There are, however, no adequate and well-controlled studies in pregnant women Because animal reproduction studies are not always predictive of human response, azithromycin should be used during pregnancy only if clearly needed.

The recommended management for bacterial sinusitis in pregnancy is to use azithromycin only if clearly needed, as there are no adequate and well-controlled studies in pregnant women.

• Pregnancy Category B indicates that azithromycin should be used with caution.
• The decision to use azithromycin should be based on the potential benefits and risks to the mother and fetus 2.

From the Research

Bacterial Sinusitis Management in Pregnancy

Overview of Bacterial Sinusitis

Bacterial sinusitis is a common problem in both children and adults, with three clinical presentations: onset with persistent symptoms, onset with severe symptoms, and onset with worsening symptoms 3. The diagnosis of bacterial sinusitis is typically clinical, with cardinal features including unilateral facial pain or pressure, fever greater than 102°F (39°C), and purulent nasal discharge with obstruction of the nasal passages 4.

Treatment of Bacterial Sinusitis

• Antibiotics should be considered for patients with 3 or more days of severe symptoms, significant worsening after 3 to 5 days of symptoms, or 7 or more days of symptoms 4.
• Amoxicillin is as effective as amoxicillin-clavulanate as a first-line treatment for acute bacterial rhinosinusitis for those without a beta-lactam allergy 4.
• 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 4.
• Supportive care for rhinosinusitis, including use of saline irrigation, nasal steroids or antihistamines, and decongestants, may help reduce the severity of symptoms 4.
• The optimal duration of therapy is unknown, but some recommend treatment until the patient becomes free of symptoms and then for an additional 7 days 3.
• Short-course antibiotic therapy (less than or equal to 5 days) may have equivalent or superior efficacy compared with traditional longer (10-14 days) therapies 5.

Considerations in Pregnancy

While there is no specific guidance on the management of bacterial sinusitis in pregnancy, the general principles of treatment apply. It is essential to weigh the benefits and risks of antibiotic use in pregnant women, considering the potential effects on the fetus and the mother 6, 7.

Key Points

• Bacterial sinusitis is a clinical diagnosis, and antibiotics should be considered based on the severity and duration of symptoms.
• Amoxicillin is a suitable first-line treatment for acute bacterial rhinosinusitis.
• Supportive care can help reduce the severity of symptoms.
• The optimal duration of therapy is unknown, but short-course antibiotic therapy may be effective.