What is the recommended treatment for acute sinusitis?

Treatment of Acute Sinusitis

Amoxicillin-clavulanate is the recommended first-line antibiotic treatment for acute bacterial sinusitis, with a dosage of 875/125 mg twice daily for 5-7 days in adults, along with appropriate adjunctive treatments. 1

Diagnosis and Patient Selection

Before initiating treatment, it's crucial to determine if the sinusitis is bacterial rather than viral:

• Consider bacterial sinusitis when one of these patterns is present:

  • 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 ("double-sickening") 1

• Clinical features suggesting bacterial sinusitis:

  • Maxillary pain or tenderness (especially when unilateral)
  • Purulent nasal secretions
  • Symptoms lasting ≥10 days 2

Antibiotic Treatment Algorithm

1. First-line therapy:

   • Amoxicillin-clavulanate: 875/125 mg twice daily for 5-7 days 1, 3
   • For less severe cases: Amoxicillin 500 mg twice daily 1

2. High-risk patients (consider high-dose therapy):

   • Age <2 or >65 years
   • Recent antibiotic use
   • Recent hospitalization
   • Comorbidities or immunocompromised state
   • High prevalence of resistant S. pneumoniae in area
   • High-dose amoxicillin-clavulanate: 2000 mg (amoxicillin component) with 125 mg clavulanate twice daily 1

3. Penicillin-allergic patients:

   • Cefuroxime: 250-500 mg twice daily
   • Cefpodoxime: 200-400 mg twice daily
   • Cefdinir: 300-600 mg twice daily
   • For severe allergies: Levofloxacin 500 mg daily or Moxifloxacin 400 mg daily 1

4. Renal impairment adjustments:

   • GFR <30 mL/min: Avoid 875/125 mg dose
   • GFR 10-30 mL/min: Use 500/125 mg or 250/125 mg every 12 hours
   • GFR <10 mL/min: Use 500/125 mg or 250/125 mg every 24 hours 3

Adjunctive Treatments

These should be used alongside antibiotics for symptom relief:

• Intranasal corticosteroids: Reduce inflammation
• Saline nasal irrigation: Clears secretions and reduces congestion
• Analgesics: Acetaminophen or ibuprofen for pain and fever
• Oral or topical decongestants: Short-term use only (≤3-5 days for topical to avoid rebound congestion) 1

Treatment Monitoring and Follow-up

• Evaluate patients after 3-5 days of treatment to assess response 1
• If no improvement within 72 hours:
  • Consider switching to broader-spectrum antibiotic
  • Re-evaluate diagnosis
  • Consider complications requiring specialist referral 1

When to Refer to Specialist

• Symptoms persisting beyond 3 weeks despite appropriate therapy
• Signs of complications:
  • Orbital involvement (eye swelling, vision changes)
  • Severe headache or altered mental status
  • Persistent high fever
  • Immunocompromised patients with poor response 1

Common Pitfalls to Avoid

1. Overdiagnosis of bacterial sinusitis: Most cases of acute rhinosinusitis are viral in origin. Antibiotics should be reserved for patients meeting specific criteria for bacterial infection 2, 4

2. Inappropriate antibiotic selection: Using broad-spectrum antibiotics as first-line treatment increases resistance and costs without improving outcomes 5, 6

3. Inadequate duration of treatment: Stopping antibiotics too early can lead to treatment failure

4. Relying on imaging for initial diagnosis: Radiography is not recommended for routine diagnosis of uncomplicated acute sinusitis 2, 4

5. Failing to address underlying conditions: Allergic rhinitis, anatomic variations, or immunodeficiency may contribute to recurrent or chronic sinusitis 1

By following this evidence-based approach to diagnosing and treating acute sinusitis, clinicians can improve outcomes while minimizing unnecessary antibiotic use and reducing complications.