What antibiotic should be used for a sinus infection if Augmentin (amoxicillin/clavulanate) provided some improvement but symptoms of pressure persist?

From the Guidelines

If Augmentin provided some improvement for your sinus infection but pressure symptoms persist, doxycycline (100 mg twice daily for 5-7 days) would be a reasonable next option. This recommendation is based on the most recent and highest quality study available, which suggests that doxycycline or a respiratory fluoroquinolone may be used as an alternative in patients with acute bacterial rhinosinusitis (ABRS) who have not shown improvement with initial treatment 1.

Key Considerations

• Before switching antibiotics, it's essential to complete the full course of Augmentin as prescribed, as incomplete treatment can contribute to antibiotic resistance.
• Persistent symptoms might also indicate that the infection needs more time to resolve, or could suggest other issues like allergies or structural problems that antibiotics alone won't address.
• Saline nasal irrigation, decongestants, and pain relievers can help manage symptoms while the antibiotics work.
• If symptoms worsen or don't improve after a complete course of antibiotics, medical evaluation is necessary to rule out complications or alternative diagnoses.

Alternative Options

• A respiratory fluoroquinolone like levofloxacin (750 mg once daily for 5 days) could be considered, especially if symptoms are severe or if there's concern about resistant bacteria.
• These alternatives work through different mechanisms than Augmentin and may be effective against bacteria that have developed resistance.

Evidence-Based Recommendations

• The American College of Physicians and the Centers for Disease Control and Prevention recommend reserving antibiotic treatment for acute rhinosinusitis for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever, or worsening symptoms after an initial period of improvement 1.
• The Infectious Diseases Society of America (IDSA) clinical practice guidelines recommend empirical antibiotics as soon as a clinical diagnosis of ABRS is established on the basis of clinical criteria, with amoxicillin–clavulanate as the preferred agent, and doxycycline or a respiratory fluoroquinolone as alternatives 1.

From the FDA Drug Label

Levofloxacin is approved for the treatment of acute bacterial sinusitis (ABS) using either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days 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)

If Augmentin (amoxicillin/clavulanate) provided some improvement but symptoms of pressure persist, levofloxacin may be considered as an alternative antibiotic for the treatment of acute bacterial sinusitis. The 750 mg once daily for 5 days or 500 mg once daily for 10 to 14 days regimens may be used. However, it is essential to note that the choice of antibiotic should be based on the specific circumstances of the patient and the suspected or confirmed causative pathogen. 2

From the Research

Antibiotic Options for Sinus Infection

If Augmentin (amoxicillin/clavulanate) provided some improvement but symptoms of pressure persist, the following antibiotic options can be considered:

• Respiratory fluoroquinolones (i.e., moxifloxacin, gatifloxacin, and levofloxacin) 3
• Ceftriaxone 3
• High-dose amoxicillin-clavulanate (4 g of amoxicillin/day and 250 mg of clavulanate/day) 3
• Levofloxacin, which has been shown to be as effective and better tolerated than amoxicillin-clavulanate 4
• Moxifloxacin, which has been found to be equivalent to amoxicillin/clavulanate in terms of clinical and bacteriological response 5, 6

Considerations for Antibiotic Selection

When selecting an antibiotic, consider the following factors:

• The patient's history of antibiotic use in the previous 4-6 weeks 3
• The severity of the disease, with fluoroquinolones often recommended as second-line therapy or as first-line therapy for selected patients with moderate-to-severe disease 3
• The patient's allergy status, with alternatives such as cefuroxime, cefpodoxime, or cefdinir available for penicillin-allergic patients 7
• The optimal duration of therapy, which is unknown but may involve treatment until the patient becomes free of symptoms and then for an additional 7 days 7