What is the recommended treatment for sinusitis?

Treatment of Sinusitis

Amoxicillin is the first-line antibiotic treatment for acute sinusitis, with a standard course of 10-14 days, while more severe or unresponsive cases require broader-spectrum antibiotics like amoxicillin-clavulanate. 1

Initial Treatment Approach for Acute Sinusitis

First-Line Antibiotic Therapy

• Amoxicillin: First choice for both children and adults
  • Generally effective, inexpensive, and well tolerated
  • Standard dosing for 10-14 days
  • Continue until patient is symptomatically improved to near normal

For Patients Allergic to Amoxicillin

• Alternative options include:
  • Cephalosporins (cefuroxime, cefpodoxime, cefprozil, cefdinir)
  • Macrolides
  • Quinolones (in adults)

For Poor Response to Initial Treatment

If no improvement after 3-5 days of amoxicillin:

1. Switch to high-dose amoxicillin-clavulanate (90 mg/kg amoxicillin and 6.4 mg/kg clavulanate, not to exceed 2g every 12 hours)
2. Alternative options: cefuroxime axetil or other broader-spectrum antibiotics 1

Adjunctive Treatments

Nasal Corticosteroids

• May be helpful in both acute and chronic sinusitis
• Particularly useful when there is marked mucosal edema or nasal polyposis

Supportive Measures

• Adequate hydration
• Adequate rest
• Analgesics as needed
• Warm facial packs
• Steamy showers
• Sleeping with head of bed elevated
• Treatment of underlying allergies if present 1

Treatment Based on Response

Partial Response

• Continue antibiotic treatment for another 10-14 days
• Or consider switching to broader-spectrum antibiotics

Poor Response

• For poor response to amoxicillin or trimethoprim-sulfamethoxazole:
  • High-dose amoxicillin-clavulanate
  • Cefuroxime
  • Cefpodoxime
  • Cefprozil
  • Cefdinir
  • Consider quinolones or macrolides 1

Treatment Failure After Extended Course

For sinusitis that fails to improve after 21-28 days of initial antibiotic treatment:

• Consider broader-spectrum single agents (high-dose amoxicillin-clavulanate, cefuroxime, cefpodoxime)
• Consider adding anaerobic coverage with clindamycin or metronidazole
• Evaluate for underlying risk factors
• Consider sinus CT scan
• Consider specialist consultation (allergist-immunologist or otolaryngologist) 1

Special Considerations

Chronic Sinusitis (symptoms >8 weeks)

• Consider non-infectious forms of sinusitis
• Systemic corticosteroids may be needed
• Surgical consultation may be appropriate for anatomic abnormalities or nasal polyps

Recurrent Sinusitis

• Evaluate for underlying inflammation, allergy, immunodeficiency, and anatomic abnormalities
• Consider referral to specialist for comprehensive evaluation 1

Common Pitfalls to Avoid

1. Failing to distinguish viral from bacterial sinusitis
2. Not allowing adequate time for antibiotic response (3-5 days)
3. Inadequate duration of therapy (should be 10-14 days for acute sinusitis)
4. Not addressing underlying factors (allergies, structural abnormalities)
5. Not considering antibiotic resistance patterns in your region
6. Failing to recognize complications requiring urgent intervention (orbital or intracranial involvement)

The FDA has approved levofloxacin for acute bacterial sinusitis in either a 5-day high-dose regimen (750 mg daily) or a 10-14 day standard dose regimen (500 mg daily), with comparable efficacy rates between the two regimens 2. However, fluoroquinolones should generally be reserved for cases where first-line agents have failed or are contraindicated.