What are the first-line and second-line medications for treating sinusitis?

From the Guidelines

For the treatment of sinusitis, the first-line medication is amoxicillin (45 mg/kg per day in 2 divided doses) or amoxicillin-clavulanate (45 mg/kg per day) for children with uncomplicated acute bacterial sinusitis, with adjustments based on severity, age, and resistance patterns, as recommended by 1.

Key Considerations

• The choice of antibiotic should consider the risk of resistance, with amoxicillin-clavulanate being an option for patients at higher risk of resistant organisms.
• For patients with severe illness, younger than 2 years, attending child care, or recently treated with an antimicrobial, high-dose amoxicillin-clavulanate (80–90 mg/kg per day) may be considered.
• A single dose of ceftriaxone (50 mg/kg) can be used for children who are vomiting or unable to tolerate oral medication, with a switch to oral therapy after clinical improvement.

Second-Line Treatments

• For patients with hypersensitivity to amoxicillin, alternatives such as cefdinir, cefuroxime, or cefpodoxime can be used, as suggested by 1.
• Broader-spectrum antibiotics like doxycycline or levofloxacin may be considered for patients with penicillin allergies or treatment failures.

Important Notes

• Antibiotics should only be prescribed for bacterial sinusitis, with clear signs or symptoms persisting beyond 10 days.
• The optimal duration of antimicrobial therapy is typically 10 days, but can be adjusted based on clinical response, with a minimum of 7 days after the patient becomes free of signs and symptoms.
• The treatment approach should be individualized, taking into account the patient's specific circumstances, such as attendance at child care, recent antimicrobial treatment, and age, as discussed in 1.

From the Research

First-Line Medications for Sinusitis

• Amoxicillin with clavulanate is a commonly recommended first-line treatment for acute bacterial sinusitis in adults 2, 3
• The standard dose of amoxicillin with clavulanate is 875/125 mg, taken twice a day for 7-10 days 2, 3
• Other first-line options may include doxycycline, cefpodoxime, and cefuroxime 4

Second-Line Medications for Sinusitis

• High-dose amoxicillin with clavulanate (1750 mg of IR amoxicillin twice a day) may be considered as a second-line treatment for adults with acute bacterial sinusitis who do not respond to standard-dose treatment 2
• Other second-line options may include fluoroquinolones such as moxifloxacin or gatifloxacin 5, 6
• Macrolides and cephalosporins may also be considered as second-line treatments, although their effectiveness may vary depending on the specific patient population and antibiotic resistance patterns 4

Indications for Antibiotic Treatment

• Antibiotics are typically reserved for patients with acute bacterial sinusitis, which is characterized by persistent or severe symptoms such as nasal congestion, facial pain, and purulent discharge 4
• Patients with viral sinusitis or mild symptoms may not require antibiotic treatment and can be managed with supportive care such as saline nasal washes, steam inhalation, and topical corticosteroids 4