What is the recommended treatment for a sinus infection?

Recommended Treatment for Sinus Infections

The recommended first-line treatment for bacterial sinusitis is amoxicillin or amoxicillin-clavulanate for 5-7 days, along with adjunctive therapies including intranasal corticosteroids, saline irrigation, and decongestants. 1

Diagnosis of Bacterial Sinusitis

Before initiating treatment, it's important to determine if the sinus infection is bacterial, which is characterized by:

• Persistent symptoms: Nasal discharge or cough for >10 days without improvement
• Severe symptoms: High fever (>39°C/102.2°F) with purulent nasal discharge or facial pain for ≥3 consecutive days
• Worsening symptoms: Initial improvement followed by worsening of nasal discharge, cough, or fever 1

Antibiotic Treatment Algorithm

First-Line Options:

• Amoxicillin: Standard dose for uncomplicated cases
• Amoxicillin-clavulanate: 875/125 mg twice daily for 5-7 days (preferred first choice according to the American Academy of Pediatrics) 1

Alternative Options (for penicillin allergy or treatment failure):

• Cephalosporins:

  • Cefuroxime: 250-500 mg twice daily for 5-7 days
  • Cefpodoxime: 200-400 mg twice daily for 5-7 days
  • Cefdinir: 300-600 mg twice daily for 5-7 days

• Fluoroquinolones (reserved for treatment failures or complicated cases):

  • Levofloxacin: 750 mg once daily for 5 days 2
  • Moxifloxacin: 400 mg once daily for 5-7 days 1

Important Antibiotic Considerations:

• Avoid Cephalexin (Keflex) as it provides inadequate coverage against common respiratory pathogens, particularly Haemophilus influenzae 1
• Assess for improvement within 72 hours of starting antibiotics
• Consider switching to a broader-spectrum antibiotic if no improvement is seen 1

Adjunctive Treatments

These treatments should be used alongside antibiotics to improve symptoms and facilitate recovery:

1. Intranasal corticosteroids: Reduce inflammation and promote drainage 1
2. Saline nasal irrigation: Helps clear mucus and reduce congestion
3. Oral decongestants: Reduce nasal congestion (use with caution in patients with hypertension)
4. Topical decongestants: For short-term use only (≤3 days) to avoid rebound congestion
5. Analgesics: Acetaminophen or ibuprofen for pain and fever 1

Special Considerations

For Persistent Symptoms:

• If symptoms persist despite appropriate antibiotic therapy and adjunctive treatments for 3 weeks, consider referral to an otolaryngologist 1
• Surgical intervention may be necessary for drainage of the infected area 1

Warning Signs Requiring Immediate Referral:

• Orbital involvement (eye swelling, visual changes)
• Severe headache or altered mental status
• Persistent high fever despite antibiotics
• Signs of spread beyond the sinuses 1

Management of Underlying Conditions

• Allergic rhinitis: Treat with antihistamines and intranasal corticosteroids
• Environmental triggers: Advise avoidance of known allergens and irritants
• Adequate hydration: Encourage increased fluid intake to thin mucus secretions 1

Common Pitfalls to Avoid

1. Treating viral sinusitis with antibiotics: Most cases of acute sinusitis are viral and resolve without antibiotics within 7-10 days
2. Using antibiotics for too short a duration: Inadequate treatment duration can lead to recurrence
3. Failing to address underlying conditions: Allergic rhinitis, nasal polyps, or anatomical abnormalities may predispose to recurrent sinusitis
4. Overuse of topical decongestants: Can lead to rebound congestion (rhinitis medicamentosa)
5. Neglecting adjunctive therapies: Antibiotics alone may not provide optimal symptom relief without supportive measures

By following this treatment algorithm and considering both antibiotic therapy and adjunctive treatments, most cases of acute bacterial sinusitis can be effectively managed with good outcomes for morbidity, mortality, and quality of life.