What is the best antibiotic for resistant sinusitis?

From the Guidelines

For resistant sinusitis, amoxicillin-clavulanate (Augmentin) at a high dose of 875/125 mg twice daily for 5-7 days is typically the best first-line antibiotic choice. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of appropriate antibiotic use for acute respiratory tract infections, including sinusitis 1. The American College of Physicians and the Centers for Disease Control and Prevention recommend amoxicillin-clavulanate as the preferred agent, with doxycycline or a respiratory fluoroquinolone as alternative options for patients with acute bacterial rhinosinusitis (ABRS) 1.

Some key points to consider when treating resistant sinusitis include:

• The use of adjunctive therapy, such as intranasal saline irrigation or intranasal corticosteroids, to alleviate symptoms and potentially decrease antibiotic use 1
• The importance of completing the full course of antibiotics, even if symptoms improve before finishing 1
• The potential need for culture-directed therapy based on endoscopic sinus cultures if multiple antibiotic courses fail 1
• The consideration of referral to an ENT specialist for evaluation of possible surgical intervention if multiple antibiotic courses fail 1

It's also important to note that acute uncomplicated rhinosinusitis is a self-limited infection that usually resolves without antibiotics, and most patients diagnosed with acute rhinosinusitis have more adverse effects than benefits from antibiotics 1. Therefore, antibiotic treatment should be reserved for patients with persistent symptoms or severe disease, and supportive care, such as analgesics and antipyretics, should be offered to manage symptoms 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 In a controlled double-blind study conducted in the U.S., moxifloxacin hydrochloride tablets (400 mg once daily for ten days) were compared with cefuroxime axetil (250 mg twice daily for ten days) for the treatment of acute bacterial sinusitis. The trial included 457 patients valid for the efficacy analysis Clinical success (cure plus improvement) at the 7 to 21 day post-therapy test of cure visit was 90% for moxifloxacin hydrochloride and 89% for cefuroxime.

The best antibiotic for resistant sinusitis is levofloxacin or moxifloxacin, as both have shown high clinical success rates in treating acute bacterial sinusitis.

• Levofloxacin: 91.4% clinical success rate at the test-of-cure visit for the 750 mg dose, and 88.6% for the 500 mg dose 2
• Moxifloxacin: 90% clinical success rate at the 7 to 21 day post-therapy test of cure visit 3

From the Research

Treatment Options for Resistant Sinusitis

• The choice of antibiotic for treating resistant sinusitis depends on various factors, including the severity of the infection and the patient's medical history 4, 5.
• Amoxicillin with clavulanate is a commonly recommended treatment for acute bacterial sinusitis in adults, but its effectiveness can be limited due to antibiotic resistance 6, 7.
• Alternative antibiotics, such as levofloxacin, may be effective in treating acute sinusitis, with a success rate of 88.4% compared to 87.3% for amoxicillin-clavulanate 8.

Comparison of Antibiotic Effectiveness

• A study comparing high-dose amoxicillin plus clavulanate to standard-dose amoxicillin plus clavulanate found no significant difference in efficacy between the two treatments 7.
• Another study found that adults with clinically diagnosed acute bacterial sinusitis were more likely to improve rapidly when treated with high-dose immediate-release amoxicillin/clavulanate, but not when treated with extended-release high-dose amoxicillin/clavulanate 6.
• Levofloxacin has been shown to be as effective as amoxicillin-clavulanate in treating acute sinusitis, with fewer adverse events 8.

Adverse Events and Tolerability

• High-dose amoxicillin plus clavulanate has been associated with a higher incidence of severe diarrhea compared to standard-dose amoxicillin plus clavulanate 6, 7.
• Levofloxacin has been shown to be better tolerated than amoxicillin-clavulanate, with fewer adverse events such as nausea, diarrhea, and abdominal pain 8.