What is the treatment for sinusitis?

Treatment of Sinusitis

Antibiotics are the primary treatment for acute bacterial sinusitis, with amoxicillin or amoxicillin-clavulanate being the first-line choices for most patients. 1

Diagnosis and Classification

• Acute sinusitis is defined as symptoms and signs lasting less than 4 weeks, with diagnosis primarily based on clinical history and physical examination 1
• Bacterial sinusitis should be suspected when symptoms persist for more than 10 days without improvement, when symptoms are severe (high fever, purulent nasal discharge for 3-4 consecutive days), or when symptoms worsen after initial improvement 2
• Common clinical findings include purulent rhinorrhea (often unilateral), facial pain/pressure that worsens when bending forward, and nasal congestion 1

Antibiotic Treatment for Acute Bacterial Sinusitis

First-line Treatment Options:

• Amoxicillin: 500 mg twice daily for adults; 45 mg/kg twice daily for children 1
• Amoxicillin-clavulanate: 500-875 mg twice daily for adults; 22.5-45 mg/kg twice daily for children (based on amoxicillin component) 1
• For regions with high bacterial resistance or for more severe cases, high-dose amoxicillin-clavulanate is recommended 1, 2

Alternative Options (for penicillin-allergic patients):

• Second-generation cephalosporins: Cefuroxime axetil (250-500 mg twice daily) 1
• Third-generation cephalosporins: Cefpodoxime proxetil (200-400 mg twice daily), cefdinir 1
• Macrolides: Azithromycin (250 mg daily, typically 5-day course after 500 mg loading dose) or clarithromycin (500 mg twice daily) 1, 3
• Respiratory fluoroquinolones (for severe cases or treatment failures): Levofloxacin (500 mg daily) or moxifloxacin (400 mg daily) 1, 4

Duration of Treatment:

• Standard duration is 10-14 days for most antibiotics 1
• Some newer agents like azithromycin may be effective with shorter courses (3-5 days) 5, 6
• Treatment should continue until the patient is symptom-free for 7 days 1

Treatment Algorithm Based on Severity and Response

Mild Acute Bacterial Sinusitis:

1. Start with amoxicillin or amoxicillin-clavulanate 1
2. Assess response after 3-5 days 1
3. If improving, continue for full course (10-14 days) 1
4. If not improving after 3-5 days, switch to a different antibiotic (high-dose amoxicillin-clavulanate, cefuroxime, or cefpodoxime) 1

Moderate to Severe Sinusitis or Recent Antibiotic Use:

1. Start with high-dose amoxicillin-clavulanate or respiratory fluoroquinolone 1
2. Consider combination therapy for severe cases 1
3. If no improvement after 3-5 days, consider sinus imaging and specialist referral 1

Adjunctive Treatments

• Intranasal corticosteroids: May be helpful in both acute and chronic sinusitis, especially with marked mucosal edema 1
• Decongestants (oral or topical): May help decrease nasal resistance and improve sinus drainage, though evidence is limited 1
• Antihistamines: Not recommended for acute bacterial sinusitis but may be beneficial in chronic sinusitis if allergic rhinitis is an underlying factor 1
• Comfort measures: Adequate hydration, analgesics, warm facial packs, steamy showers, and sleeping with head elevated 1

Special Considerations

• Chronic or recurrent sinusitis: Evaluate for underlying conditions such as allergies, immunodeficiency, or anatomical abnormalities 1
• Frontal, ethmoidal, or sphenoidal sinusitis: These require more aggressive treatment due to higher risk of complications; respiratory fluoroquinolones may be considered 1
• Complications: Signs of orbital involvement (proptosis, periorbital edema) or neurological symptoms require immediate hospitalization and parenteral antibiotics 1

Treatment Failure

• If symptoms persist after 21-28 days of antibiotic treatment, consider broader-spectrum antibiotics, anaerobic coverage with clindamycin or metronidazole, CT imaging, and specialist referral 1
• Consider possible resistant pathogens, presence of nasal polyps, or non-compliance with treatment 1

Remember that antibiotic treatment is inappropriate for uncomplicated viral upper respiratory tract infections and should be reserved for cases with clear evidence of bacterial infection 1.