What is the recommended treatment for sinusitis?

Recommended Treatment for Sinusitis

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

Diagnosis and Classification

Before initiating treatment, it's important to distinguish between:

• Viral sinusitis (most common, self-limiting)
• Acute bacterial sinusitis (ABRS)
• Chronic rhinosinusitis (symptoms lasting ≥12 weeks)

Clinical presentations suggesting bacterial sinusitis include:

• Persistent symptoms (nasal symptoms/cough for >10 but <30 days without improvement)
• Severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days)
• Worsening symptoms (initial improvement followed by deterioration) 2

Treatment Algorithm for Acute Bacterial Sinusitis

First-line Treatment

• Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days 1
• For severe infection, immunocompromised hosts, or areas with high S. pneumoniae resistance: High-dose regimen of 2000 mg amoxicillin with 125 mg clavulanate twice daily for 5-7 days 1

Alternative Options (for penicillin allergy)

• Cefdinir: 300-600 mg twice daily for 5-7 days
• Cefuroxime: 250-500 mg twice daily for 5-7 days
• Cefpodoxime: 200-400 mg twice daily for 5-7 days
• For serious drug allergies: Respiratory fluoroquinolones (levofloxacin 500 mg daily or moxifloxacin 400 mg daily) 1

Special Considerations

• Children should receive antibiotics for 10-14 days 1
• Patients with treatment failure after 7 days should be reassessed and switched to a different antibiotic class 1

Adjunctive Therapies

• Intranasal saline irrigation (strongly recommended)
• Intranasal corticosteroids (recommended alongside antibiotics)
• Decongestants (for symptomatic relief)
• Short course of oral corticosteroids may help with moderate to severe symptoms 1

Treatment for Chronic Rhinosinusitis

For chronic rhinosinusitis (symptoms lasting ≥12 weeks):

1. First-line: Nasal saline irrigation and intranasal corticosteroid sprays 3
2. Antibiotics only if evidence of acute infection
3. Consider referral to otolaryngologist if medical management fails
4. Endoscopic sinus surgery may be needed for refractory cases 3

Important Clinical Pearls

Microbiology

• Main pathogens in acute sinusitis: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 4
• Chronic sinusitis: Anaerobic bacteria and Staphylococcus aureus predominate 4
• Pseudomonas aeruginosa is common in immunocompromised patients 4

Common Pitfalls to Avoid

• Treating viral URI as bacterial sinusitis
• Using fluoroquinolones as first-line therapy
• Inadequate duration of therapy
• Not reassessing after 72 hours if symptoms worsen
• Unnecessary imaging 1

Evidence Update

Recent research shows no significant benefit of high-dose amoxicillin-clavulanate over standard-dose therapy. In a 2021 randomized clinical trial, 44.3% of patients on standard-dose vs 36.4% on high-dose reported significant improvement at day 3 5, suggesting standard dosing is appropriate for most patients.

While traditional recommendations suggested 10-14 days of antibiotics, current evidence supports shorter 5-7 day courses for uncomplicated acute maxillary sinusitis in adults 1, 6.