What to do for acute bacterial sinusitis persisting despite 5 days of Augmentin (amoxicillin/clavulanate)?

Management of Acute Bacterial Sinusitis Persisting Despite 5 Days of Augmentin

For acute bacterial sinusitis that persists despite 5 days of amoxicillin-clavulanate (Augmentin), switch to a different antibiotic with broader coverage such as a respiratory fluoroquinolone like levofloxacin, along with adjunctive intranasal corticosteroids. 1

Assessment of Treatment Failure

When evaluating a patient with persistent symptoms after 5 days of Augmentin, determine whether this represents:

• Poor response: Little or no symptomatic improvement after initial antibiotic therapy 1
• Partial response: Some improvement but not back to normal at the end of the first course 1

Key clinical considerations:

• Presence of fever, worsening facial pain, or headache
• Purulent nasal discharge
• Facial swelling or erythema that could indicate complications
• Duration and progression of symptoms

Treatment Algorithm

1. Antibiotic Therapy

• First choice: Switch to a respiratory fluoroquinolone such as levofloxacin 750 mg once daily for 5 days 2

  • Levofloxacin has demonstrated clinical success rates of 91.4% in acute bacterial sinusitis 2
  • The 5-day regimen is as effective as longer courses 2, 3

• Alternative options if fluoroquinolones are contraindicated:

  • Cefuroxime axetil 500 mg twice daily for 7-10 days 1
  • Cefpodoxime, cefprozil, or cefdinir 1
  • Consider adding clindamycin or metronidazole for anaerobic coverage in severe cases 1

2. Adjunctive Therapy

• Intranasal corticosteroids: Add to antibiotic therapy, especially if marked mucosal edema is present 1
• Short-course oral corticosteroids: Consider in patients with severe symptoms or nasal polyps 1
• Supportive measures:
  • Adequate hydration
  • Analgesics for pain control
  • Warm facial packs
  • Saline nasal irrigation
  • Sleeping with head elevated 1

Rationale for Treatment Change

Persistence of symptoms after 5 days of Augmentin suggests:

1. Resistant pathogens: Bacteria not adequately covered by initial therapy 1

   • Common resistant organisms include penicillin-resistant Streptococcus pneumoniae and beta-lactamase producing Haemophilus influenzae 4

2. Inadequate drug concentration: Standard-dose amoxicillin-clavulanate may be insufficient for resistant strains 5

3. Alternative diagnosis: Consider other conditions that mimic sinusitis:

   • Allergic rhinitis
   • Viral upper respiratory infection
   • Nasal polyps
   • Sinonasal tumors 1

Follow-up Recommendations

• Schedule follow-up within 7 days to assess response to the new antibiotic regimen 1
• If symptoms persist despite 21-28 days of appropriate antibiotic therapy:
  • Consider CT imaging of sinuses 1
  • Evaluate for underlying risk factors (allergies, immunodeficiency, anatomic abnormalities) 1
  • Consider referral to an otolaryngologist or allergist-immunologist 1

Important Caveats

• Duration of therapy: While traditional recommendations suggest 10-14 days, evidence supports that shorter courses (5-7 days) of appropriate antibiotics are equally effective with fewer adverse effects 3, 6

• High-dose vs. standard-dose: Recent evidence suggests that high-dose amoxicillin-clavulanate does not provide additional benefit over standard-dose for most patients 5

• Antibiotic stewardship: Ensure the diagnosis of bacterial sinusitis is accurate before initiating or changing antibiotics 1

• Warning signs: Instruct patients to seek immediate medical attention if they develop severe headache, visual changes, facial swelling, or neurologic symptoms 1