What are the options for second-line therapy for sinusitis?

From the Guidelines

Second-line therapy for sinusitis should prioritize non-antibiotic approaches, such as a course of systemic corticosteroids, especially for chronic hyperplastic eosinophilic rhinosinusitis, which does not respond to antibiotics 1. When considering second-line therapy for sinusitis, it's essential to evaluate the patient's condition and determine the underlying cause of the sinusitis.

• Chronic sinusitis, defined as signs and symptoms persisting 8 weeks or longer, may require a different approach than acute sinusitis.
• A coronal sinus CT with extra cuts through the ostiomeatal complex can help clarify the extent of disease and specific location or locations 1.
• Nasal-sinus biopsy may be necessary in suspected cases of neoplasia, fungal disease, granulomatous disease, or to evaluate ciliary structures and function 1.
• For patients with significant nasal septal deviation, middle turbinate deformity, or obstructing nasal polyps, consultation with an otolaryngologist may be necessary to consider surgical intervention, such as functional endoscopic sinus surgery 1.
• Medical treatment for underlying rhinitis should be maximized before proceeding with surgical intervention, and individualized medical therapy, including allergy management, should be continued after surgery 1.
• Systemic corticosteroids may be considered for patients with chronic hyperplastic eosinophilic rhinosinusitis, which is marked by a preponderance of eosinophils and mixed mononuclear cells, with a relative paucity of neutrophils 1.

From the FDA Drug Label

1.4 Acute Bacterial Sinusitis: 5 Day and 10 to 14 Day Treatment Regimens Levofloxacin tablets are indicated for the treatment of acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis

1.6 Acute Bacterial Sinusitis Moxifloxacin hydrochloride tablets are a fluoroquinolone antibacterial indicated for treating infections in adults 18 years of age and older caused by designated susceptible bacteria, in the conditions listed below: Acute Bacterial Sinusitis (1.6)

The options for second-line therapy for sinusitis are:

• Levofloxacin: indicated for the treatment of acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis 2
• Moxifloxacin: indicated for the treatment of acute bacterial sinusitis in adults 18 years of age and older caused by designated susceptible bacteria 3 Key points to consider when choosing a second-line therapy for sinusitis include:
• The causative pathogens and their susceptibility patterns
• The severity of the infection
• The patient's medical history and potential drug interactions It is essential to consult the full prescribing information and consider the specific clinical scenario before making a decision.

From the Research

Second-Line Therapy Options for Sinusitis

The following are options for second-line therapy for sinusitis:

• Respiratory fluoroquinolones, such as moxifloxacin, gatifloxacin, and levofloxacin, which are often recommended as second-line therapy or as first-line therapy for selected patients 4, 5, 6
• High-dose amoxicillin-clavulanate (4 g of amoxicillin/day and 250 mg of clavulanate/day) 4
• Ceftriaxone 4
• Other fluoroquinolones, such as levofloxacin, which are reserved for cases of sinusitis with risk of complications and for second-line treatment after failure in patients with acute maxillary sinusitis 6

Clinical Efficacy of Second-Line Therapy Options

Studies have shown that second-line therapy options, such as moxifloxacin and gatifloxacin, have high clinical success rates and are well-tolerated 5, 7

• A study found that moxifloxacin therapy resulted in rapid bacteriological eradication, with a high rate of clinical success (92.6%) 5
• Another study compared the clinical efficacy of short-course (5-day) gatifloxacin with standard 10-day regimens of amoxicillin/clavulanate or gatifloxacin in patients with acute bacterial sinusitis, and found that the clinical cure rates were comparable between the treatment groups 7

Bacterial Species Implicated in Sinusitis

The predominant bacterial species implicated in acute sinusitis are:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis in children 8
• These bacteria are often resistant to beta-lactams and macrolides, making second-line therapy options necessary 4, 8