What is the recommended treatment for sinus infections?

Recommended Treatment for Sinus Infections

For sinus infections, the recommended first-line treatment is amoxicillin-clavulanate, accompanied by intranasal corticosteroids and saline irrigation. 1

Diagnosis and Classification

• Acute bacterial sinusitis can present in three ways: persistent symptoms (>10 but <30 days without improvement), severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days), or worsening symptoms after initial improvement 2
• Most cases of acute sinusitis (duration <3 weeks) are caused by viral rhinosinusitis ("the common cold") rather than bacterial infection 3
• It is clinically difficult to distinguish viral from bacterial sinusitis, which often leads to overdiagnosis and overtreatment 4

Antibiotic Therapy

Acute Bacterial Sinusitis

• For acute bacterial sinusitis, the recommended antibiotic treatment is:
  • First-line: Amoxicillin-clavulanate 1, 2
  • For penicillin-allergic patients: Cephalosporins (cefuroxime, cefpodoxime, cefprozil, or cefdinir) 1, 2
  • For serious drug allergies: Macrolides like azithromycin or clarithromycin 2
• The FDA-approved dosage for azithromycin in acute bacterial sinusitis is 500 mg once daily for 3 days 5
• Consider withholding antibiotics for the first week in mild cases, as many will resolve spontaneously 3, 4

Chronic Sinusitis

• For chronic sinusitis, a minimum 3-week course of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae is recommended 3
• The American Academy of Allergy, Asthma, and Immunology recommends high-dose amoxicillin-clavulanate as first-line therapy for chronic ethmoid sinusitis 1

Adjunctive Therapies

• Intranasal corticosteroids are strongly recommended to reduce inflammation in both acute and chronic sinusitis 3, 1, 6
  • For chronic sinusitis, continue intranasal corticosteroids for 3 months after symptoms resolve 3
• Saline irrigation helps improve mucociliary clearance and reduce nasal congestion (recommended 2-3 times daily) 1, 7
• Short-term oral decongestants (like oxymetazoline) may be used for up to 5 days to improve ostial patency 3, 1
  • Caution: Prolonged use can lead to rhinitis medicamentosa (rebound congestion) 1
• Supportive measures include adequate hydration, analgesics, warm facial packs, and sleeping with the head elevated 6

Treatment Duration

• For acute bacterial sinusitis: 7-10 days of antibiotics is standard, though some cephalosporins have shown effectiveness with 5-day courses 6, 2
• For chronic sinusitis: A minimum of 3 weeks of antibiotic treatment is recommended 3

Special Considerations

Sphenoid Sinusitis

• Presents with characteristic retro-orbital headache that radiates to the vertex 6
• Requires prompt antibiotic treatment with amoxicillin-clavulanate, second/third generation cephalosporins, or fluoroquinolones active against pneumococci 6
• Immediate surgical management is indicated if neurological complications develop 6

Dental-Origin Sinusitis

• Usually unilateral and requires dental care along with antibiotics effective against anaerobic bacteria (amoxicillin-clavulanate or pristinamycin) 8

Common Pitfalls to Avoid

• Overdiagnosis and overtreatment of sinusitis is common in primary care practice 4
• Prolonged use of decongestants beyond 5 days can lead to rhinitis medicamentosa 1
• Antihistamines should only be used when a patient has concomitant allergies that are symptomatic 7
• Delayed specialist referral in cases with complications can worsen outcomes 1
• Inadequate antibiotic spectrum or duration, especially for chronic sinusitis, can lead to treatment failure 1

When to Consider Surgical Intervention

• For documented chronic sinus infection refractory to medical therapy with anatomic obstruction 3
• Development of complications, particularly neurological or visual disturbances 6, 9
• Referral to an otolaryngologist should be considered for medically resistant cases 1