What is the best antibiotic for otitis and sinusitis?

Best Antibiotics for Otitis and Sinusitis

Amoxicillin-clavulanate is the first-line empiric treatment for both acute bacterial sinusitis and otitis media, with respiratory fluoroquinolones reserved for treatment failures or penicillin allergies. 1

Acute Bacterial Sinusitis

First-Line Treatment

• Amoxicillin-clavulanate is recommended by the Infectious Diseases Society of America as first-line therapy 1
  • Standard dose: 875/125 mg twice daily for 5-7 days
  • High-dose (for severe cases or areas with high S. pneumoniae resistance): 2000 mg amoxicillin component with 125 mg clavulanate twice daily for 5-7 days

Alternative Options (for penicillin allergy)

• Cephalosporins:
  • 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
• Respiratory fluoroquinolones (for treatment failures or severe allergies):
  • Levofloxacin: 500 mg once daily for 5-7 days
  • Moxifloxacin: 400 mg once daily for 5-7 days

Treatment Failure

• Treatment failure is defined as persistent symptoms after 7 days of antibiotic therapy 1
• For treatment failures, switch to a respiratory fluoroquinolone (levofloxacin or moxifloxacin) 1
• Consider CT scan of paranasal sinuses and referral to otolaryngology for recurrent or chronic sinusitis 1

Acute Otitis Media

First-Line Treatment

• Azithromycin has shown excellent efficacy for otitis media in children 2
  • Dosing: 10 mg/kg on day 1, followed by 5 mg/kg on days 2-5
  • Clinical success rates of 88% at day 11 and 73% at day 30
  • Lower incidence of gastrointestinal side effects compared to alternatives (9% vs 31%)

Alternative Options

• Amoxicillin-clavulanate is an effective alternative 2
• For penicillin allergies, consider macrolides or cephalosporins

Important Clinical Considerations

Bacterial Pathogens

• Primary pathogens in both conditions 1, 2, 3:
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis

Duration of Therapy

• Adults with sinusitis: 5-7 days 1
• Children with sinusitis: 10-14 days 1
• Otitis media: 5 days for azithromycin 2

Adjunctive Therapies

• For sinusitis:
  • Intranasal saline irrigation
  • Intranasal corticosteroids
  • Short-course decongestants for symptomatic relief

Monitoring and Follow-up

• Reassess after 72 hours of antibiotic therapy 1
• If no improvement after 7 days, switch to a different antibiotic class 1

Common Pitfalls to Avoid

1. Treating viral infections with antibiotics: Ensure diagnosis meets criteria for bacterial infection
2. Inadequate dosing: Use appropriate weight-based dosing in children
3. Ignoring local resistance patterns: Consider local S. pneumoniae resistance when selecting therapy
4. Premature antibiotic changes: Allow 72 hours for clinical response before changing therapy
5. Overlooking allergies: Document and consider antibiotic allergies when selecting therapy

Side Effects

• Amoxicillin-clavulanate: Higher rates of gastrointestinal side effects (diarrhea 32%, nausea 12%) 2
• Azithromycin: Lower rates of GI side effects (diarrhea 4-9%, vomiting 2-6%) 2, 4
• Fluoroquinolones: Generally well-tolerated but should be reserved for treatment failures due to resistance concerns 1, 5

Remember to reassess patients who fail to improve after 72 hours of appropriate antibiotic therapy, as this may indicate resistant organisms or complications requiring specialist referral.