What is the treatment for sinus infection?

Treatment for Sinus Infection

For acute purulent maxillary sinusitis, first-line antibiotic therapy should include amoxicillin-clavulanate or second/third-generation cephalosporins such as cefuroxime-axetil or cefpodoxime-proxetil for 7-10 days. 1

Diagnosis and Classification

• Acute sinusitis is defined as symptoms lasting less than 3 weeks, while chronic sinusitis persists beyond 12 weeks 2
• Clinical diagnosis of acute bacterial sinusitis is based on purulent rhinorrhea (anterior and/or posterior, often unilateral) and pain upon pressure in the area over the infected sinus cavity 1
• Different types of sinusitis include maxillary (most common), frontal, ethmoidal, and sphenoidal, each with distinct symptoms and treatment considerations 1

Treatment Algorithm

Step 1: Determine if Antibiotics are Necessary

• Antibiotics are indicated when:
  • Symptoms of acute purulent maxillary sinusitis are established 1
  • Symptoms last more than 7-10 days or include severe symptoms with high fever and purulent nasal discharge 2
  • Patient has frontal, ethmoidal, or sphenoidal sinusitis (these always require antibiotic therapy) 1
• Antibiotics are NOT indicated when:
  • Nasal symptoms remain diffuse, bilateral, and of moderate intensity with serous discharge in an epidemic context 1
  • Symptoms are consistent with viral rhinosinusitis 3

Step 2: Select Appropriate Antibiotic

• First-line options for maxillary sinusitis:
  • Amoxicillin-clavulanate 1
  • Second-generation cephalosporins: cefuroxime-axetil 1
  • Third-generation cephalosporins: cefpodoxime-proxetil, cefotiam-hexetil 1
  • Pristinamycin (for patients with beta-lactam allergies) 1
• For frontal, ethmoidal, or sphenoidal sinusitis:
  • Same as above, OR
  • Fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) - reserved for situations with risk of major complications 1, 4

Step 3: Determine Treatment Duration

• Standard duration: 7-10 days 1
• Shorter course (5 days) may be effective with certain antibiotics like cefuroxime-axetil and cefpodoxime-proxetil 1
• Levofloxacin can be used at 750mg once daily for 5 days or 500mg once daily for 10-14 days for acute bacterial sinusitis 4

Step 4: Add Adjunctive Therapies

• Intranasal corticosteroids are the cornerstone of treatment, especially for chronic sinusitis 5, 2
• Saline irrigation prevents crusting of secretions and facilitates mechanical removal of mucus 1, 5
• Short-term corticosteroids may be useful as adjuvant therapy in acute hyperalgic sinusitis 1
• Decongestants may provide symptomatic relief by widening ostia and reducing turbinate swelling 5, 6
• Mucolytics and expectorants may provide symptomatic benefit in selected cases 5, 6

Special Considerations

For Chronic Sinusitis

• Intranasal corticosteroids are the primary treatment 5
• Longer duration of antibiotic therapy may be required, with attention to anaerobic pathogens 5
• Evaluate and treat underlying conditions such as allergic rhinitis, GERD, and immunodeficiency 5, 7

For Sinusitis with Cough

• First-generation antihistamine/decongestant combinations may be helpful for cough specifically related to postnasal drip 2
• Upper Airway Cough Syndrome (UACS) should be considered as part of the diagnosis 2

When to Refer to a Specialist

• When sinusitis is refractory to standard treatment 5, 2
• For recurrent episodes (more than 3-4 per year) 2
• When complications or anatomical abnormalities are suspected 2
• For signs of complicated sinusitis: meningeal syndrome, exophthalmos, palpebral edema, ocular mobility disorders, or severe pain preventing sleep 1

Common Pitfalls

• Overdiagnosis and overtreatment of acute bacterial sinusitis in primary care practice 3
• Overuse of antibiotics for viral sinusitis 5, 3
• Failure to consider underlying conditions like allergic rhinitis that may complicate sinusitis 7
• Inadequate duration of therapy or inappropriate antibiotic selection 8