What is the management of acute and chronic sinusitis in adults and children?

Management of Sinusitis in Adults and Children

Amoxicillin with or without clavulanate is the first-line treatment for acute bacterial sinusitis in both adults and children, with specific diagnostic criteria determining when antibiotics are necessary versus when observation is appropriate. 1, 2

Diagnosis of Acute Bacterial Sinusitis

Clinical Presentations Warranting Antibiotic Consideration

1. Persistent illness: Nasal discharge (any quality) or daytime cough or both lasting >10 days without improvement 1, 2
2. Worsening course: Worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement ("double-sickening") 1, 2
3. Severe onset: Concurrent fever (≥39°C/102.2°F) and purulent nasal discharge for at least 3 consecutive days 1, 2

Important Diagnostic Considerations

• Imaging is NOT recommended for uncomplicated acute bacterial sinusitis diagnosis 1, 2
• Only obtain contrast-enhanced CT scan when orbital or central nervous system complications are suspected 1, 2
• Up to 87% of young adults recovering from colds and 42% of healthy children show sinus abnormalities on imaging, making clinical diagnosis more reliable 2

Treatment Algorithm for Acute Bacterial Sinusitis

Children (1-18 years)

1. For severe onset or worsening course: Prescribe antibiotic therapy immediately 1

2. For persistent illness: Either prescribe antibiotic therapy or offer additional observation for 3 days 1

3. First-line antibiotic: Amoxicillin with or without clavulanate 1, 2

   • Standard dosing: Amoxicillin 45 mg/kg twice daily 1
   • High-risk for resistance: Amoxicillin-clavulanate (based on amoxicillin component) 45 mg/kg twice daily 1

4. For penicillin allergy: Cefdinir, cefuroxime (7.5 mg/kg BID), or cefpodoxime (5 mg/kg BID) 1, 2

   • Note: Risk of serious allergic reaction to second- and third-generation cephalosporins in patients with penicillin allergy is minimal 1

5. Duration: Continue therapy for 7 days after patient becomes symptom-free (minimum course of 10 days) 1

6. Reassessment: If symptoms worsen or fail to improve within 72 hours of initial management, reassess and consider changing antibiotics 1

Adults

1. First-line antibiotic: Amoxicillin 500 mg twice daily or amoxicillin-clavulanate 500-875 mg twice daily 1

2. For penicillin allergy:

   • Cefuroxime 250-500 mg twice daily
   • Cefpodoxime 200-400 mg twice daily 1

3. For severe penicillin allergy: Clarithromycin 500 mg twice daily 1

   • Note: Azithromycin is NOT recommended due to high resistance rates among common pathogens 2, 3

4. Duration: 5-7 days for uncomplicated cases; 7-10 days for patients with risk factors for antibiotic resistance 1

5. Reassessment: If no improvement after 3-5 days, consider changing antibiotics 1

Risk Factors for Antibiotic Resistance

• Age <2 or >65 years
• Recent antibiotic use (within past month)
• Daycare attendance
• Prior hospitalization (past 5 days)
• Comorbidities or immunocompromised state 1

Management of Chronic Sinusitis

• Antibiotics: For acute exacerbations of chronic sinusitis, amoxicillin-clavulanate is recommended 1
• Nasal corticosteroids: May be helpful in both acute and chronic sinusitis 1
• Oral corticosteroids: Consider short-term use as adjunct therapy when patient fails to respond to initial treatment, has nasal polyps, or marked mucosal edema 1
• Surgical consultation: Consider for patients who fail medical management 1

Special Considerations

• Severely ill patients: Two options:

  1. Otolaryngology consultation for maxillary sinus aspiration for culture
  2. Inpatient therapy with IV cefotaxime or ceftriaxone 1

• Children with nasal polyps: Consider evaluation for cystic fibrosis 1

• Antihistamines: No data to recommend use in acute bacterial sinusitis; may have a role in chronic sinusitis if underlying allergic rhinitis is present 1

Common Pitfalls to Avoid

1. Unnecessary imaging: Plain radiographs have significant false-positive and false-negative results 1

2. Inappropriate antibiotic use: Antibiotics should not be prescribed for uncomplicated viral upper respiratory infections 1

3. Using ineffective antibiotics: Trimethoprim/sulfamethoxazole and azithromycin should be avoided due to high resistance rates 2

4. Inadequate follow-up: Failure to reassess patients who aren't improving within 72 hours of starting treatment 1

5. Insufficient treatment duration: Stopping antibiotics too early can lead to treatment failure and recurrence 1