What are the current Australian guidelines for treating maxillary sinusitis?

Current Australian Guidelines for Management of Maxillary Sinusitis

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

Diagnosis of Acute Bacterial Sinusitis

Diagnosis should be based on one of the following clinical patterns:

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

First-line Antibiotic Treatment

Adults:

• First choice: Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days 1
• High-dose option: Amoxicillin-clavulanate 2000/125 mg twice daily for 5-7 days (for areas with high pneumococcal resistance) 1

Children:

• First choice: Amoxicillin-clavulanate at appropriate weight-based dosing 1
• Alternative: Amoxicillin 45 mg/kg twice daily 1

Alternative Antibiotics (for penicillin allergy)

• Cefuroxime: 250-500 mg twice daily for 5-7 days 1, 2
• Cefpodoxime: 200-400 mg twice daily for 5-7 days 1
• Cefdinir: 300-600 mg twice daily for 5-7 days 1
• Levofloxacin: 500 mg once daily for 5-7 days (reserve for treatment failures or complicated cases) 1
• Moxifloxacin: 400 mg once daily for 5-7 days (reserve for treatment failures or complicated cases) 1

Risk Factors for Resistant Organisms

Consider high-dose therapy or broader-spectrum antibiotics in patients with:

• Age <2 or >65 years
• Recent antibiotic use (within previous 30 days)
• Recent hospitalization
• Significant comorbidities
• Immunocompromised state
• Daycare attendance (pediatric patients)
• Residence in areas with high prevalence of penicillin-resistant S. pneumoniae 3, 1

Adjunctive Treatments

• Intranasal corticosteroids: Reduce inflammation and improve sinus drainage
• Saline nasal irrigation: Helps clear mucus and reduce congestion
• Analgesics: Acetaminophen or ibuprofen for pain and fever
• Decongestants: Short-term use (3-5 days) of oral or topical decongestants 1

Treatment Monitoring and Follow-up

• Assess for clinical improvement within 72 hours of starting antibiotics
• If no improvement after 3-5 days, consider switching to a broader-spectrum antibiotic
• Immediate specialist referral for signs of complications (orbital involvement, severe pain, persistent fever) 1

Surgical Intervention

• Consider referral to an otolaryngologist if symptoms persist despite appropriate antibiotic therapy and adjunctive treatments
• Surgical intervention may be necessary for persistent symptoms beyond 3 weeks despite antibiotic therapy 1

Common Pitfalls to Avoid

• Overdiagnosis: Not all cases of sinusitis are bacterial; many are viral or allergic in origin
• Inadequate duration: Ensure complete course of antibiotics (5-7 days)
• Failure to address underlying conditions: Identify and treat allergic rhinitis or immunodeficiency
• Delayed referral: Promptly refer patients with signs of complications or treatment failure
• Antibiotic resistance: Be aware of local resistance patterns when selecting antibiotics 1

Microbiology Considerations

The major bacterial pathogens in acute bacterial sinusitis are:

• Streptococcus pneumoniae (approximately 30%)
• Haemophilus influenzae (approximately 30%)
• Moraxella catarrhalis (approximately 10%)
• About 25-30% of maxillary sinus aspirates may be sterile 3

Staphylococcus aureus is rarely isolated in uncomplicated acute bacterial sinusitis but is a significant pathogen in orbital and intracranial complications 3.