What is the first line treatment for an adult with a sinus infection?

First-Line Treatment for Adult Sinus Infection

Amoxicillin or amoxicillin-clavulanate is the recommended first-line treatment for adults with acute bacterial sinusitis, with watchful waiting (without antibiotics) as an appropriate alternative for uncomplicated cases. 1, 2

Diagnosis of Acute Bacterial Sinusitis

Before initiating treatment, it's important to distinguish bacterial sinusitis from viral causes:

• Persistent symptoms: Nasal discharge or cough 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 ("double-sickening") 1

Treatment Algorithm

Step 1: Consider Watchful Waiting vs. Antibiotics

• Watchful waiting is appropriate for uncomplicated cases with mild symptoms 2
• Immediate antibiotics should be considered for:
  • Severe symptoms (high fever, severe pain)
  • Symptoms lasting >10 days without improvement
  • Immunocompromised patients
  • Elderly patients (>65 years)

Step 2: First-Line Antibiotic Options

• Standard risk patients:

  • Amoxicillin: 500 mg twice daily for 5-7 days 1

• High-risk patients (age >65, recent antibiotic use, high local prevalence of resistant S. pneumoniae):

  • Amoxicillin-clavulanate: 875/125 mg twice daily for 5-7 days 1
  • High-dose amoxicillin-clavulanate: 2000 mg (amoxicillin component) with 125 mg clavulanate twice daily for 5-7 days 1

Step 3: Alternative Options (Penicillin Allergy)

• Non-severe penicillin allergy:

  • Cefuroxime: 250-500 mg twice daily for 5-7 days 1
  • Cefpodoxime: 200-400 mg twice daily for 5-7 days 1
  • Cefdinir: 300-600 mg twice daily for 5-7 days 1

• Severe penicillin allergy:

  • Levofloxacin: 500 mg once daily for 5-7 days 1, 3
  • Moxifloxacin: 400 mg once daily for 5-7 days 1

Adjunctive Treatments

In addition to antibiotics (or during watchful waiting), consider:

• Intranasal corticosteroids: Reduce inflammation and improve drainage 1
• Saline nasal irrigation: Helps clear mucus and reduce congestion 1
• Analgesics: Acetaminophen or ibuprofen for pain and fever 1
• Oral decongestants: Short-term use to improve nasal patency 1

Monitoring and Follow-up

• Assess for clinical improvement within 72 hours of starting antibiotics 1
• If no improvement after 3-5 days, consider:
  • Switching to a broader-spectrum antibiotic
  • Reevaluating diagnosis
  • Referral to specialist if complications suspected 1

Common Pitfalls to Avoid

1. Overuse of antibiotics: Not all sinus infections require antibiotics; viral causes are common and self-limiting 4
2. Inadequate duration: While shorter courses (5-7 days) are often sufficient, premature discontinuation can lead to treatment failure 5
3. Ignoring underlying conditions: Allergic rhinitis, asthma, and nasal polyps can complicate sinusitis and require specific management 6
4. Failure to recognize complications: Watch for orbital involvement, severe pain, or persistent fever, which require immediate referral 1

Special Considerations

• Recent antibiotic use: Choose a different class of antibiotic or amoxicillin-clavulanate 1
• Immunocompromised patients: May require longer treatment duration and broader coverage 1
• Recurrent sinusitis: Consider referral to otolaryngologist to evaluate for anatomic abnormalities or chronic sinusitis 1

The evidence strongly supports either watchful waiting or antibiotic therapy with amoxicillin or amoxicillin-clavulanate as first-line treatment for acute bacterial sinusitis in adults, with the decision based on symptom severity, duration, and patient risk factors 2, 1.