What is the first line treatment for sinusitis?

First-Line Treatment for Sinusitis

The first-line treatment for acute bacterial sinusitis is amoxicillin-clavulanate, with alternatives including second and third generation cephalosporins (cefuroxime-axetil, cefpodoxime-proxetil, cefotiam-hexetil) or pristinamycin for patients with penicillin allergies. 1, 2

Diagnosis and Initial Management

• Acute bacterial sinusitis should be differentiated from viral upper respiratory infections, as antibiotics are only indicated when the diagnosis of acute bacterial sinusitis is established 1
• Antibiotic therapy is indicated when there is:
  • Unilateral or bilateral infraorbital pain that increases when bending forward 1
  • Purulent rhinorrhea (anterior and/or posterior, often unilateral) 1
  • Persistence of symptoms beyond 10 days or worsening of symptoms after initial improvement 3

Antibiotic Selection and Duration

• Amoxicillin-clavulanate is the preferred first-line treatment due to increasing prevalence of beta-lactamase-producing organisms 1, 2
• For patients with penicillin allergies, alternatives include:
  • Second/third generation cephalosporins (cefuroxime-axetil, cefpodoxime-proxetil) 1, 2
  • Pristinamycin 1, 2
• Standard duration of treatment is 7-10 days, though some cephalosporins have shown effectiveness in 5-day courses 1, 2
• For acute bacterial sinusitis, azithromycin can be given as 500 mg daily for 3 days as an alternative regimen 4

Adjunctive Therapies

• Decongestants (topical or systemic) can be used short-term to reduce nasal congestion and facilitate drainage 1, 5
• Caution: Topical decongestants should not be used for more than 3 days due to risk of rhinitis medicamentosa (rebound congestion) 1
• Intranasal corticosteroids may be beneficial as adjunctive therapy, particularly when there is marked mucosal edema 2, 6
• Saline nasal irrigation and adequate hydration can help with mucus clearance 5

Special Considerations

• For maxillary sinusitis of dental origin, antibiotic therapy is definitely indicated 1
• For frontal, ethmoidal, or sphenoidal sinusitis, which carry higher risk of complications, antibiotic therapy is mandatory 1, 7
• Fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) should be reserved for:
  • Treatment failures with first-line antibiotics 1
  • High-risk sinusitis (frontal, fronto-ethmoidal, sphenoidal) 1, 7

Treatment Failure

• If no improvement is seen within 3-5 days of starting antibiotics, reevaluation is necessary 2
• For poor response to initial therapy, switch to an antibiotic that covers resistant bacteria, such as high-dose amoxicillin-clavulanate or fluoroquinolones 2
• Clinical signs suggestive of complicated sinusitis (meningeal syndrome, exophthalmos, palpebral edema, ocular mobility disorders, severe pain) require hospitalization, bacteriological testing, and parenteral antibiotic therapy 1, 7

Pediatric Considerations

• For children with acute bacterial sinusitis, amoxicillin-clavulanate remains the first-line treatment 2
• Azithromycin for pediatric sinusitis is dosed at 10 mg/kg once daily for 3 days 4
• OTC cough and cold medications should be avoided in children under 6 years of age due to potential toxicity and lack of proven efficacy 1