What is the recommended treatment for bacterial sinusitis?

Treatment of Bacterial Sinusitis

Amoxicillin-clavulanate is the first-line empiric antimicrobial therapy for acute bacterial sinusitis in both adults and children, with treatment duration of 5-7 days for adults and 10-14 days for children. 1

Diagnosis of Bacterial Sinusitis

Proper diagnosis is crucial to avoid unnecessary antibiotic use. Bacterial sinusitis should be diagnosed when patients present with:

• Persistent symptoms for >10 days without improvement
• Severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days)
• Worsening symptoms after initial improvement (double sickening) 1, 2

The most common bacterial pathogens in acute bacterial sinusitis are:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
• Staphylococcus aureus 1

First-Line Treatment

Adults:

• Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days 1
• High-dose amoxicillin-clavulanate (2000 mg amoxicillin component twice daily) should be considered in:
  • Regions with high prevalence of penicillin-resistant S. pneumoniae
  • Severe infection
  • Immunocompromised hosts
  • Extremes of age
  • Recent hospitalization
  • Recent antibiotic use 1

Children:

• Amoxicillin-clavulanate with weight-based dosing (45 mg/kg BID for amoxicillin component) for 10-14 days 1

Alternative Antibiotic Options

For patients with penicillin allergy or treatment failures:

• Doxycycline
• Cefuroxime
• Cefpodoxime
• Cefdinir
• Levofloxacin (reserved for treatment failures or when other options cannot be used) 1, 3

The FDA label for levofloxacin indicates it is approved for acute bacterial sinusitis at a dose of 750 mg once daily for 5 days or 500 mg once daily for 10-14 days 3. However, fluoroquinolones should be reserved for cases where other antibiotics cannot be used due to resistance concerns and side effect profiles.

Adjunctive Therapies

• Recommended:

  • Intranasal saline irrigation with either physiologic or hypertonic saline
  • Intranasal corticosteroids (especially in patients with history of allergic rhinitis) 1

• Not Recommended:

  • Topical or oral decongestants
  • Antihistamines 1

Monitoring and Treatment Failure

Treatment should be reassessed if:

• Symptoms worsen after 48-72 hours of initial therapy
• Symptoms fail to improve after 3-5 days of initial therapy 1

Treatment failure may indicate:

• Resistant pathogens
• Inadequate penetration of antibiotics
• Incorrect diagnosis 1

Common Pitfalls to Avoid

1. Overdiagnosis: Not distinguishing between viral and bacterial sinusitis leads to unnecessary antibiotic use 1

2. Monitoring failure: Failing to reassess treatment response at 72 hours can lead to continuation of ineffective therapy 1

3. Side effects: Monitor for diarrhea, which is a common side effect with amoxicillin-clavulanate, occurring in approximately 40% of patients 1

4. Inadequate duration: Especially in children, insufficient treatment duration can lead to treatment failure 1

5. Inappropriate antibiotic selection: Not considering local resistance patterns when selecting antibiotics 1

Short-course therapy (5-7 days) for adults has been shown to be as effective as traditional 10-14 day courses, which can improve compliance and reduce side effects 1, 4.