What are the recommended antibiotics (Abx) for treating a sinus infection?

Recommended Antibiotics for Sinus Infections

For acute bacterial sinusitis, first-line treatment should be amoxicillin-clavulanate, with second and third generation cephalosporins (cefuroxime-axetil, cefpodoxime-proxetil) as alternatives, and pristinamycin for patients with beta-lactam allergies. 1

Antibiotic Selection by Sinus Type

Maxillary Sinusitis (Most Common)

• First-line therapy:
  • Amoxicillin-clavulanate 1
• Alternatives:
  • 2nd generation cephalosporins: cefuroxime-axetil
  • 3rd generation cephalosporins: cefpodoxime-proxetil, cefotiam-hexetil
  • For penicillin allergy: pristinamycin 1

Frontal, Ethmoidal, or Sphenoidal Sinusitis

• First-line therapy: Same as maxillary sinusitis
• Alternative/severe cases: Fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) 1, 2, 3
  • Note: Reserve fluoroquinolones for complicated cases or when first-line therapy fails 1

Treatment Duration

• Standard treatment duration: 7-10 days 1
• Some cephalosporins (cefuroxime-axetil, cefpodoxime-proxetil) have shown efficacy in 5-day regimens 1
• For recurrent sinusitis, treatment may need to be extended to 3-4 weeks 4

Special Considerations

When to Use Antibiotics

Antibiotic therapy is indicated when:

• Initial symptomatic treatment fails
• Complications occur
• Unilateral maxillary sinusitis associated with dental infection
• Frontal, ethmoidal, or sphenoidal sinusitis (always requires antibiotics) 1

Signs of Complicated Sinusitis (Requiring Immediate Treatment)

• Meningeal syndrome
• Exophthalmos
• Palpebral edema
• Ocular mobility disorders
• Pain preventing sleep 1

Pediatric Considerations

For children with acute maxillary sinusitis:

• First-line therapy:
  • Amoxicillin-clavulanate (80 mg/kg/day in three doses, not exceeding 3 g/day)
  • Cefpodoxime-proxetil (8 mg/kg/day in two doses) 1

Treatment Failure

If first-line therapy fails in maxillary sinusitis:

1. Perform bacteriological and/or radiological investigations
2. Consider fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) 1, 2, 3

Common Pitfalls

• Prescribing antibiotics for viral rhinosinusitis (common cold) which does not require antibiotic therapy 1
• Using fluoroquinolones as first-line therapy when they should be reserved for treatment failures or complicated cases 1
• Using outdated antibiotics with high resistance rates (aminopenicillins alone, macrolides, first-generation cephalosporins, cotrimoxazole) 1
• Failing to recognize complications requiring immediate treatment or referral 4

Adjunctive Therapies

• Short-term corticosteroids may be beneficial for acute hyperalgic sinusitis 1
• Saline irrigation can help with mucus clearance 4
• Mucolytics/expectorants may provide symptomatic benefit 4

When to Refer

Consider referral to an ENT specialist when:

• Patient experiences 2-3 episodes per year despite appropriate treatment
• Condition significantly affects quality of life
• Nasal polyps are suspected or present
• Complex pharmacology is needed for resistant pathogens 4

Remember that while antibiotics are important for treating bacterial sinusitis, proper diagnosis is crucial to avoid unnecessary antibiotic use and the development of resistance.