What are the treatment guidelines for acute bacterial sinusitis?

Treatment Guidelines for Acute Bacterial Sinusitis

Amoxicillin-clavulanate is the recommended first-line antibiotic treatment for acute bacterial sinusitis, with appropriate treatment duration of 5-7 days for most patients. 1

Diagnosis of Acute Bacterial Sinusitis

Accurate diagnosis is essential before initiating antibiotics. Acute bacterial sinusitis can be diagnosed when any of these clinical presentations are present:

1. Persistent symptoms - Symptoms lasting ≥10 days without clinical improvement
2. Severe symptoms - High fever (≥39°C/102°F) and purulent nasal discharge or facial pain for ≥3-4 consecutive days
3. Worsening symptoms - Initial improvement followed by worsening symptoms ("double-sickening") 2, 1

First-Line Antibiotic Treatment

• Amoxicillin-clavulanate (875/125 mg twice daily for 5-7 days) is the recommended first-line treatment 1
• Standard-dose amoxicillin-clavulanate is as effective as high-dose formulations, with similar clinical success rates 3

Alternative Antibiotic Options

For patients with penicillin allergy or treatment failure:

Alternative	Dosage	Duration
Cefuroxime	250-500 mg twice daily	5-7 days
Cefpodoxime	200-400 mg twice daily	5-7 days
Cefdinir	300-600 mg twice daily	5-7 days
Levofloxacin	500 mg once daily	5-7 days
Moxifloxacin	400 mg once daily	5-7 days

Important note: Fluoroquinolones (levofloxacin, moxifloxacin) should be reserved for patients who have no alternative treatment options due to their potential for serious adverse reactions 4, 5

Risk Factors for Antibiotic Resistance

Consider using broader-spectrum antibiotics if these risk factors are present:

• Age <2 or >65 years
• Recent antibiotic use (within past month)
• Recent hospitalization (past 5 days)
• Comorbidities or immunocompromised state
• Daycare attendance 2

Treatment Algorithm

1. Assess severity and risk factors:

   • Determine if symptoms meet criteria for bacterial sinusitis
   • Evaluate risk factors for antibiotic resistance

2. Initial treatment decision:

   • No risk factors: Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days
   • Risk factors present: Consider second-line therapy or high-dose amoxicillin-clavulanate

3. Evaluate response after 3-5 days:

   • Improvement: Complete 5-7 day course
   • No improvement or worsening: Switch to different antibiotic class or broaden coverage

4. Consider specialist referral if:

   • No response to second-line therapy
   • Signs of complications (orbital involvement, severe pain, persistent fever)
   • Symptoms persist beyond 3 weeks despite appropriate therapy 1

Adjunctive Treatments

These can be used alongside antibiotics to manage symptoms:

• Intranasal corticosteroids
• Saline nasal irrigation
• Oral or topical decongestants (short-term use)
• Acetaminophen or ibuprofen for pain and fever 1

Common Pitfalls to Avoid

1. Overdiagnosis of bacterial sinusitis - Most cases of sinusitis are viral, not bacterial. Ensure patients meet specific diagnostic criteria before prescribing antibiotics.

2. Inappropriate antibiotic selection - Avoid using cephalexin as it provides inadequate coverage against common respiratory pathogens, particularly Haemophilus influenzae 1

3. Excessive fluoroquinolone use - Reserve levofloxacin and moxifloxacin for patients with no other options due to risk of serious adverse effects 4, 5

4. Inadequate duration reassessment - Evaluate patients after 3-5 days of treatment to determine if antibiotic change is needed 2, 1

5. Missing complications - Be vigilant for signs of complicated sinusitis requiring immediate referral (orbital involvement, severe pain, persistent fever) 1