What is the best treatment approach for a 35-year-old female (YOF) with recurring sinus infections, previously treated with amoxicillin and azithromycin, now presenting with another sinus infection and an acute asthma exacerbation?

From the Guidelines

For a 35-year-old female with recurring sinus infections and an acute asthma exacerbation, the best treatment approach is to use a fluoroquinolone antibiotic such as levofloxacin 750 mg daily for 5-7 days, in combination with a short course of oral corticosteroids like prednisone 40 mg daily for 5 days, and increased use of a short-acting beta-agonist inhaler like albuterol 2 puffs every 4-6 hours as needed. This approach is based on the most recent and highest quality evidence available, which suggests that fluoroquinolones are effective against a broad range of pathogens, including those that may be resistant to other antibiotics 1. The use of oral corticosteroids and short-acting beta-agonist inhalers is also supported by evidence, as they can help reduce airway inflammation and improve symptoms in patients with asthma exacerbations 1. Additionally, the patient should use a nasal corticosteroid spray like fluticasone 1-2 sprays in each nostril daily and saline nasal irrigation twice daily to improve sinus drainage. Key considerations in the treatment of this patient include:

• The need for broad-spectrum antibiotic coverage due to the patient's history of recurring sinus infections and previous antibiotic exposures
• The importance of addressing both the infectious and inflammatory components of the patient's condition
• The potential benefits of using intranasal corticosteroids and saline nasal irrigation to improve sinus drainage and reduce inflammation
• The need for careful evaluation and management of the patient's asthma exacerbation, including the use of oral corticosteroids and short-acting beta-agonist inhalers. It is also important to consider the potential risks and benefits of different treatment approaches, including the risk of antibiotic resistance and the potential benefits of using newer antibiotics like fluoroquinolones 1. Overall, a comprehensive treatment approach that addresses both the infectious and inflammatory components of the patient's condition is likely to be the most effective in improving symptoms and preventing recurrent infections.

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)]. Clinical success rates (defined as complete or partial resolution of the pre-treatment signs and symptoms of ABS to such an extent that no further antibiotic treatment was deemed necessary) in the microbiologically evaluable population were 91.4% (139/152) in the levofloxacin 750 mg group and 88.6% (132/149) in the levofloxacin 500 mg group at the test-of-cure (TOC) visit (95% CI [-4. 2,10] for levofloxacin 750 mg minus levofloxacin 500 mg).

The best treatment approach for a 35-year-old female with recurring sinus infections, previously treated with amoxicillin and azithromycin, now presenting with another sinus infection and an acute asthma exacerbation is to use levofloxacin.

• The patient can be treated with 750 mg of levofloxacin by mouth once daily for five days or 500 mg by mouth once daily for 10 to 14 days.
• It is essential to note that the treatment of acute asthma exacerbation may require additional therapies, such as bronchodilators and corticosteroids, which are not addressed in the provided drug labels 2 2.
• The choice of levofloxacin dose and duration should be based on the severity of the infection, the patient's medical history, and the results of culture and susceptibility testing, if available.

From the Research

Treatment Approach for Recurring Sinus Infections and Acute Asthma Exacerbation

The patient's history of recurring sinus infections, previously treated with amoxicillin and azithromycin, and current presentation with another sinus infection and an acute asthma exacerbation, requires a comprehensive treatment approach.

• The use of systemic corticosteroids as an adjunctive therapy to oral antibiotics has been shown to be effective for short-term relief of symptoms in acute sinusitis 3.
• For the treatment of acute sinusitis, respiratory fluoroquinolones (e.g., moxifloxacin, gatifloxacin, and levofloxacin), ceftriaxone, and high-dose amoxicillin-clavulanate are recommended 4.
• In patients with acute asthma exacerbation, initial evaluation should include a review of historical factors, objective assessment of airflow obstruction, and initiation of therapy with controlled oxygen therapy, regular bronchodilator therapy, and systemic corticosteroids 5.
• The treatment of chronic rhinosinusitis, including nasal polyps, involves the use of topical intranasal and oral corticosteroids as the first line of therapy, with long-term treatment reducing inflammation and improving nasal symptoms 6.
• The choice of antibiotic therapy should be guided by the likelihood of bacterial infection and the patient's history of previous antibiotic use 4.

Considerations for Asthma Management

• The patient's asthma exacerbation should be managed with controlled oxygen therapy, regular bronchodilator therapy, and systemic corticosteroids 5.
• The use of ipratropium bromide or IV magnesium may be considered to reduce hospitalizations for moderate to severe exacerbations 5.
• The patient's long-term anti-inflammatory therapy and the potential incremental benefit of add-on therapy, such as a long-acting beta agonist, should be reviewed 5.

Antibiotic Therapy Options

• Levofloxacin has been shown to be as effective and better tolerated than amoxicillin-clavulanate for treating acute sinusitis in adult outpatients 7.
• Moxifloxacin is a recommended option for the treatment of acute bacterial rhinosinusitis, particularly in patients with moderate-to-severe disease or those who have received antibacterials in the previous 4-6 weeks 4.