What is the recommended monitoring and treatment plan for patients with sinusitis?

From the Guidelines

The recommended monitoring and treatment plan for sinusitis begins with distinguishing between viral and bacterial causes, with treatment focusing on symptom relief for viral cases and antibiotics for bacterial cases, such as amoxicillin (500mg three times daily for 5-10 days) as first-line therapy 1.

Key Considerations

• For viral sinusitis, treatment focuses on symptom relief with saline nasal irrigation, analgesics like acetaminophen or ibuprofen (400-600mg every 6-8 hours), and intranasal corticosteroids such as fluticasone (1-2 sprays per nostril daily) 1.
• Bacterial sinusitis typically warrants antibiotics, with amoxicillin-clavulanate (875/125mg twice daily for 5-10 days) for more severe cases or those with risk factors for resistance, and doxycycline (100mg twice daily for 5-10 days) as an alternative for penicillin-allergic patients 1.
• Patients should be monitored for symptom improvement within 3-5 days of starting antibiotics, with reassessment necessary if symptoms worsen or fail to improve to consider alternative diagnoses, resistant organisms, or complications requiring imaging or specialist referral 1.
• Chronic sinusitis (lasting >12 weeks) may require extended antibiotic courses, stronger intranasal steroids, or evaluation for underlying conditions like allergies or anatomical abnormalities, with consideration of surgical intervention for cases with anatomic obstruction or refractory disease 1.

Treatment Approach

• The primary therapy for acute bacterial sinusitis is antibiotics, with the choice based on predicted efficacy, cost, and side effects, and a 10- to 14-day course generally recommended 1.
• Adjunctive therapy, such as antihistamines, decongestants, saline irrigation, mucolytics, and expectorants, may provide symptomatic benefit in selected cases, while intranasal corticosteroids may be helpful in treating recurrent acute and chronic sinusitis 1.
• Consultation with a specialist should be sought when there is a need to clarify the allergic or immunologic basis for sinusitis, sinusitis is refractory to usual antibiotic treatment, or sinusitis is recurrent or associated with unusual opportunistic infections 1.

From the FDA Drug Label

Table 1: Dosing in Patients Aged 12 weeks (3 months) and Older INFECTIONDOSING REGIMEN Every 12 hoursEvery 12 hours 200 mg/5 mL or 400 mg/5 mL oral suspension a125 mg/5 mL or 250 mg/5 mL oral suspension a Otitis media b, sinusitis, lower respiratory tract infections, and more severe infections45 mg/kg/day every 12 hours40 mg/kg/day every 8 hours Less severe infections25 mg/kg/day every 12 hours20 mg/kg/day every 8 hours

The recommended monitoring and treatment plan for patients with sinusitis includes dosing regimens of 45 mg/kg/day every 12 hours or 40 mg/kg/day every 8 hours for more severe infections, and 25 mg/kg/day every 12 hours or 20 mg/kg/day every 8 hours for less severe infections, based on the amoxicillin component 2.

• Key considerations:
  • Patients weighing 40 kg or more should be dosed according to adult recommendations.
  • Patients with impaired renal function may require dose adjustments.
  • The duration of therapy for acute otitis media is 10 days, but the label does not specify the duration for sinusitis.

From the Research

Sinusitis Monitoring and Treatment

• The diagnosis of sinusitis can be confirmed by nasal endoscopy, sinus radiography, and culture of sinus aspirate 3
• Acute bacterial sinusitis (ABS) is an extremely common problem in both children and adults, with three clinical presentations: onset with persistent symptoms, onset with severe symptoms, and onset with worsening symptoms 4
• The predominant bacterial species implicated in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in children, with an increasing prevalence of penicillin-resistant S. pneumoniae and beta-lactamase-producing H. influenzae and M. catarrhalis 4

Treatment Options

• A 3-day course of azithromycin was as effective and well tolerated as a 10-day course of amoxicillin/clavulanic acid in adults with acute sinusitis 3
• Therapy may be initiated with high-dose amoxicillin or amoxicillin-clavulanate, with alternatives including cefuroxime, cefpodoxime, or cefdinir 4
• In cases of serious drug allergy, clarithromycin or azithromycin may be prescribed 4
• Topical nasal steroid may be beneficial in patients with less severe symptoms at baseline, but neither an antibiotic nor a topical steroid alone or in combination was effective as a treatment for acute sinusitis in the primary care setting 5

Imaging and Diagnosis

• Uncomplicated sinusitis does not require radiologic imagery, but further diagnostic evaluations may be indicated when symptoms are recurrent or refractory despite adequate treatment 6
• Noncontrast coronal computed tomographic (CT) images can define the nasal anatomy much more precisely, but clinical correlation is needed to avoid overdiagnosis of sinusitis due to nonspecific CT findings 6
• Magnetic resonance imaging (MRI) cannot define bony anatomy as well as CT, but may be used to differentiate soft-tissue structures, such as in cases of suspected fungal infection or neoplasm 6

Medication Distribution and Efficacy

• Amoxicillin/clavulanate spreads well in ENT tissues, with tissue levels of both amoxicillin and clavulanic acid higher than the Minimum Inhibitory Concentration (MIC) for the most frequent causative pathogens of sinus bacterial infections 7
• A dose of 1 g of coamoxiclav twice a day seems to be clinically effective even in patients suffering from acute episodes of chronic rhinosinusitis 7