What is the recommended treatment for sinusitis?

Treatment of Sinusitis

Amoxicillin-clavulanate is the first-line treatment for acute bacterial sinusitis, with a recommended dosage of 875/125 mg twice daily for 5-7 days. 1

Diagnosis and Classification

Before initiating treatment, it's important to differentiate between viral and bacterial sinusitis:

• Bacterial sinusitis is likely when symptoms:
  • Persist for >10 days without improvement
  • Include high fever and purulent nasal discharge for 3-4 consecutive days
  • Initially improve but then worsen ("double-worsening")

Antibiotic Treatment Options

First-line Treatment

• Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days 1
• High-dose amoxicillin-clavulanate (2000 mg amoxicillin component twice daily) for 5-7 days in areas with high prevalence of resistant S. pneumoniae 1

Alternative Options (for penicillin allergy)

• Cephalosporins (if non-Type I allergy):

  • Cefuroxime 500 mg twice daily for 5-7 days
  • Cefpodoxime 200-400 mg twice daily for 5-7 days
  • Cefdinir for 5-7 days 1

• For Type I penicillin allergy:

  • Clindamycin 300-450 mg three times daily (only if S. pneumoniae confirmed) 1
  • Consider macrolides/azalides (erythromycin, clarithromycin, azithromycin) with caution due to increasing resistance 1

Fluoroquinolones

• Levofloxacin is FDA-approved for acute bacterial sinusitis:
  • 750 mg once daily for 5 days OR
  • 500 mg once daily for 10-14 days 2
  • Should be reserved for cases where first-line agents have failed or are contraindicated due to concerns about antimicrobial resistance

Treatment Duration

• 5-7 days is typically sufficient for most uncomplicated cases in adults 1
• Longer courses (10-14 days) may be considered for more severe infections 1

Patient Monitoring

• Reassess after 72 hours of therapy to evaluate effectiveness 1
• If no improvement after 72 hours, consider:
  • Changing antibiotic therapy
  • Reevaluating diagnosis 1

Adjunctive Treatments

• For air travel-related sinus pain:
  • Acetaminophen (1000 mg)
  • Nasal decongestants
  • Saline nasal irrigation 1
  • Topical decongestant sprays (oxymetazoline) 15-30 minutes before descent 1

Special Considerations

• Patients on warfarin: Cephalosporins (cefdinir, cefpodoxime, cefuroxime) are preferred due to minimal interaction with warfarin metabolism 1
• Asthma patients: Continue using prescribed inhalers and ensure asthma is well-controlled 1
• Post-sinus surgery: Delay air travel for at least 2 weeks after uncomplicated procedures 1

When to Consider Referral

• Sinusitis refractory to usual antibiotic treatment
• Recurrent sinusitis
• Sinusitis associated with unusual opportunistic infections
• When sinusitis significantly affects quality of life 1

Common Pitfalls to Avoid

1. Overuse of antibiotics for likely viral sinusitis
2. Inadequate duration of therapy leading to treatment failure
3. Failure to reassess after 72 hours of treatment
4. Inappropriate use of fluoroquinolones as first-line therapy
5. Not considering local resistance patterns when selecting antibiotics

Recent evidence suggests that high-dose amoxicillin-clavulanate may not provide additional benefit over standard dosing in most adults with acute sinusitis, while potentially increasing the risk of adverse effects like diarrhea 3. Therefore, standard dosing should be used unless there are specific concerns about resistant pathogens.