What is the recommended treatment for acute bacterial sinusitis?

Treatment of Acute Bacterial Sinusitis

Amoxicillin-clavulanate is the recommended first-line antibiotic treatment for acute bacterial sinusitis in both adults and children, with different dosing regimens and durations based on age and disease severity. 1, 2

Antibiotic Selection and Dosing

First-line Treatment:

• Adults:

  • Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days 1, 2
  • High-dose amoxicillin-clavulanate (2000 mg amoxicillin component twice daily) for patients with risk factors for resistant pathogens 2

• Children:

  • Amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) for 10-14 days 1, 2
  • Alternative: High-dose amoxicillin (90 mg/kg per day) for 10-14 days 1, 2

For Penicillin-Allergic Patients:

• Adults with non-Type I hypersensitivity:

  • Cefuroxime (500 mg twice daily) or cefpodoxime (200-400 mg twice daily) 2

• Adults with Type I hypersensitivity:

  • Doxycycline or trimethoprim-sulfamethoxazole 2
  • Respiratory fluoroquinolones (e.g., levofloxacin) should be reserved for treatment failures or severe allergies 1, 3

• Children with penicillin allergy:

  • Trimethoprim-sulfamethoxazole or macrolides (azithromycin, clarithromycin) 1, 2

Treatment Duration

• Adults: 5-7 days is sufficient for uncomplicated cases 1, 2
• Children: Longer course of 10-14 days is recommended 1, 2

Management of Treatment Failure

If symptoms worsen after 48-72 hours or fail to improve after 3-5 days of initial therapy, consider:

1. Re-evaluation of the patient 1, 2
2. Switch to alternative antibiotic therapy: 1, 2
   • If initial therapy was amoxicillin: Switch to amoxicillin-clavulanate
   • If initial therapy was amoxicillin-clavulanate: Consider respiratory fluoroquinolone or combination therapy
   • For children: Consider ceftriaxone or combination therapy 1

Adjunctive Treatments

• Intranasal saline irrigation is recommended for adults (improves mucociliary clearance) 1, 2
• Intranasal corticosteroids are beneficial as an adjunct to antibiotics, especially in patients with history of allergic rhinitis 1, 2
• Analgesics (acetaminophen or NSAIDs) for pain relief 2
• Neither topical nor oral decongestants or antihistamines are recommended as adjunctive treatment 1

Important Considerations and Pitfalls

• Recent antibiotic use (within 4-6 weeks) is a major risk factor for resistant pathogens and should guide antibiotic selection toward broader coverage 1, 2

• Avoid fluoroquinolones as first-line agents due to FDA black box warnings (tendinitis, tendon rupture, peripheral neuropathy) and the need to preserve these agents for more serious infections 2, 3

• High-dose vs. standard-dose amoxicillin-clavulanate: Recent research shows conflicting results regarding the benefits of high-dose therapy. A 2018 study suggested benefit with immediate-release high-dose formulation 4, but a 2021 study found no significant difference between high-dose and standard-dose regimens 5

• Azithromycin is not recommended as first-line therapy due to high rates of resistance among S. pneumoniae and limited effectiveness against the major pathogens of acute bacterial sinusitis 1, 6

• Referral to a specialist is indicated for patients who are immunocompromised, continue to deteriorate despite extended courses of antibiotics, or have recurrent sinusitis 1

• Reevaluation is necessary if symptoms worsen or fail to improve, as the recommended antibiotics should provide excellent coverage against the predominant pathogens 1, 2