What are the treatment options for acute sinusitis?

Treatment Options for Acute Sinusitis

For acute bacterial sinusitis, treatment should begin with amoxicillin as first-line antibiotic therapy, along with supportive measures including adequate hydration, rest, analgesics, and nasal decongestants to improve symptoms and quality of life. 1

Antibiotic Therapy

First-Line Antibiotics

• Amoxicillin is the drug of choice for initial treatment of uncomplicated acute bacterial sinusitis in both children and adults due to its effectiveness, low cost, and good tolerability 1
• For adults, standard amoxicillin dosing is 1.5-4g/day for 10-14 days 1
• Trimethoprim-sulfamethoxazole can be used as an alternative in adults with penicillin allergy, though resistance is more common in children 1

Second-Line Antibiotics (for non-responders or high-risk patients)

• High-dose amoxicillin-clavulanate (90 mg/kg amoxicillin and 6.4 mg/kg clavulanate, not to exceed 2g every 12 hours) for patients who don't respond to amoxicillin within 3-5 days 1
• For penicillin-allergic patients, alternatives include:
  • Cephalosporins (cefuroxime axetil, cefpodoxime proxetil, cefdinir) 1
  • Macrolides (clarithromycin, azithromycin) 1, 2
  • Respiratory fluoroquinolones (levofloxacin, moxifloxacin) should be reserved for treatment failures or complicated cases 1, 3

Duration of Therapy

• Standard treatment duration is 10-14 days for most antibiotics 1
• Some newer antibiotics like cefuroxime-axetil and cefpodoxime-proxetil have shown effectiveness with shorter 5-day courses 1, 4
• Treatment should continue until the patient is symptomatically improved to near normal 1

Adjunctive Therapies

Intranasal Corticosteroids

• Nasal corticosteroids may be helpful in patients with acute sinusitis, particularly when there is significant mucosal inflammation 1
• These can help reduce inflammation and improve sinus drainage 1

Oral Corticosteroids

• Short-term use of oral corticosteroids may be reasonable as an adjunct when:
  • Patient fails to respond to initial treatment
  • Patient has nasal polyps
  • Patient has marked mucosal edema 1

Decongestants

• Nasal decongestants (like oxymetazoline) may help reduce congestion and improve sinus drainage 1
• Limited to 5 days of use to avoid rebound congestion 1
• While commonly used, evidence for efficacy in acute sinusitis is limited 1

Supportive Care

• Adequate rest and hydration 1
• Analgesics as needed for pain relief 1
• Warm facial packs and steamy showers to relieve congestion 1
• Sleeping with head of bed elevated 1

Treatment Algorithm Based on Severity and Response

For Mild Acute Sinusitis

1. Begin with supportive care measures 1
2. If bacterial infection is suspected (symptoms >10 days, severe symptoms, or worsening pattern), start amoxicillin for 10-14 days 1, 2
3. Assess response after 3-5 days 1
   • If improving: complete the course (total 10-14 days)
   • If not improving: switch to high-dose amoxicillin-clavulanate or alternative antibiotic 1

For Moderate to Severe Acute Sinusitis

1. Start with high-dose amoxicillin-clavulanate or appropriate alternative based on risk factors 1
2. Consider adding intranasal corticosteroids 1
3. For severe symptoms with marked mucosal edema, consider short course of oral corticosteroids 1
4. If no improvement after 72 hours, reevaluate and consider switching antibiotics 1

Special Considerations

• Patients with poor oro-dental condition may benefit more from antibiotic therapy 5
• Recent antibiotic use (within previous 2 months) may require broader-spectrum antibiotics due to potential resistance 5
• For sinusitis of dental origin, antibiotic therapy is definitely indicated 1
• For frontal, ethmoidal, or sphenoidal sinusitis (versus maxillary), antibiotic therapy is definitely indicated and may require broader coverage 1

Common Pitfalls to Avoid

• Overdiagnosis of bacterial sinusitis in viral upper respiratory infections - most cases are viral and resolve spontaneously within 7-10 days 1, 5
• Overuse of antibiotics for viral sinusitis - reserve antibiotics for cases with symptoms lasting >10 days, severe symptoms, or worsening pattern 1, 5
• Inadequate duration of therapy - premature discontinuation can lead to relapse 6
• Overuse of fluoroquinolones for uncomplicated cases - reserve these for treatment failures or complicated cases to prevent resistance 1
• Extended use of nasal decongestants (>5 days) - can lead to rebound congestion and rhinitis medicamentosa 1