From the Guidelines
For patients with acute sinusitis who are resistant to Augmentin (amoxicillin-clavulanate), levofloxacin (750 mg once daily for 5-7 days) is a recommended alternative antibiotic due to its excellent coverage against common sinusitis pathogens, including resistant strains 1. When considering alternative antibiotics, it's essential to take into account the patient's allergy history, local resistance patterns, and individual risk factors.
- Other options may include doxycycline (100 mg twice daily for 5-7 days) or moxifloxacin (400 mg once daily for 5-7 days), which also provide broad coverage against common sinusitis pathogens.
- For patients with non-type I penicillin allergy, clindamycin (300-450 mg three times daily for 5-7 days) plus a third-generation cephalosporin like cefpodoxime or cefdinir can be effective, as they are suitable agents for acute bacterial sinusitis 1.
- The choice of antibiotic should be guided by the most recent and highest quality evidence, which suggests that levofloxacin is a suitable alternative to Augmentin in cases of resistance 1.
- It's also important to note that the optimal duration of antimicrobial therapy for patients with acute bacterial sinusitis has not received systematic study, but recommendations based on clinical observations suggest continuing antibiotic therapy for 7 days after the patient becomes free of signs and symptoms 1.
From the FDA Drug Label
Acute Bacterial Sinusitis In a randomized, double blind, double-dummy controlled clinical trial of acute bacterial sinusitis, azithromycin (500 mg once daily for 3 days) was compared with amoxicillin/clavulanate (500/125 mg tid for 10 days). Clinical response assessments were made at Day 10 and Day 28. The primary endpoint of this trial was prospectively defined as the clinical cure rate at Day 28 For the 594 patients analyzed in the modified intent to treat analysis at the Day 10 visit, the clinical cure rate for 3 days of azithromycin was 88% (268/303) compared to 85% (248/291) for 10 days of amoxicillin/clavulanate.
In an open label, noncomparative study requiring baseline transantral sinus punctures the following outcomes were the clinical success rates at the Day 7 and Day 28 visits for the modified intent to treat patients administered 500 mg of azithromycin once daily for 3 days with the following pathogens:
PathogenAzithromycin (500 mg per day for 3 Days) Day 7Day 28 S. pneumoniae23/26 (88%)21/25 (84%) H influenzae28/32 (87%)24/32 (75%) M. catarrhalis14/15 (93%)13/15 (87%)
Alternative Antibiotic Options for Acute Sinusitis:
- Azithromycin: can be used as an alternative antibiotic for acute sinusitis in patients resistant to Augmentin (amoxicillin-clavulanate) 2.
- Moxifloxacin: is also indicated for the treatment of acute bacterial sinusitis in adults 3.
Key Considerations:
- Azithromycin has been shown to have a clinical cure rate of 88% at Day 10 and 71.5% at Day 28 in the treatment of acute bacterial sinusitis.
- Moxifloxacin is a fluoroquinolone antibiotic that should be reserved for use in patients who have no alternative treatment options due to the risk of serious adverse reactions.
From the Research
Alternative Antibiotics for Acute Sinusitis
In a patient resistant to Augmentin (amoxicillin-clavulanate) for acute sinusitis, several alternative antibiotics can be considered. The choice of antibiotic depends on various factors, including the severity of symptoms, patient's medical history, and local resistance patterns.
Options for Alternative Antibiotics
- Levofloxacin: A study published in 1999 4 found that levofloxacin was as effective as amoxicillin-clavulanate for the treatment of acute sinusitis in adults, with a success rate of 88.4% compared to 87.3% for amoxicillin-clavulanate.
- Azithromycin: A 1999 study 5 compared the efficacy and tolerability of a 3-day course of azithromycin with a 10-day course of amoxicillin/clavulanic acid in the treatment of acute sinusitis in adults, finding that azithromycin was as effective and well-tolerated as amoxicillin/clavulanic acid.
- Doxycycline: According to a 2025 review 6, doxycycline is an appropriate option for patients with a beta-lactam allergy.
- Respiratory fluoroquinolones: Also mentioned in the 2025 review 6 as a suitable alternative for patients with a beta-lactam allergy.
- Cefaclor, cefuroxime axetil, and cefixime: These antibiotics were listed as alternative options in a 1992 study 7 for patients who do not respond to amoxicillin or in areas with a high prevalence of beta-lactamase-producing bacterial species.
Considerations for Choosing an Alternative Antibiotic
When selecting an alternative antibiotic, it is essential to consider the patient's medical history, including any allergies or previous reactions to antibiotics. Additionally, the local resistance patterns and the severity of symptoms should be taken into account to ensure the chosen antibiotic is effective against the likely causative pathogens.