What are the recommended medications for treating bacterial sinus infections?

Recommended Medications for Bacterial Sinus Infections

Amoxicillin is the first-line antibiotic treatment for uncomplicated acute bacterial sinusitis in situations where antimicrobial resistance is not suspected. 1

First-Line Treatment Options

For Adults:

• Standard-dose amoxicillin (1.5 g/day divided in 2 doses) for mild cases without risk factors for resistant organisms 2
• Amoxicillin-clavulanate (1.75-4 g/250 mg per day) for patients with risk factors for resistant organisms 2
• Second and third-generation cephalosporins are alternatives:
  • Cefuroxime axetil 2
  • Cefpodoxime proxetil 2
  • Cefdinir 2, 1

For Children:

• Standard-dose amoxicillin (45 mg/kg/day in 2 divided doses) for uncomplicated cases 2, 1
• High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) in communities with high prevalence of nonsusceptible S. pneumoniae (>10%) 2, 1
• High-dose amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) for patients with risk factors 2

Risk Factors for Resistant Organisms

• Age younger than 2 years 2, 1
• Attendance at childcare 2, 1
• Antibiotic use within the previous 4-6 weeks 2, 1
• High local prevalence of resistant pathogens 2, 1

For Penicillin-Allergic Patients

• Cephalosporins (if no history of anaphylaxis): cefdinir, cefuroxime, or cefpodoxime 2, 1
• Macrolides: azithromycin, clarithromycin (note: increasing resistance limits effectiveness) 2
• Trimethoprim-sulfamethoxazole (for adults, but resistance is more common in children) 2
• Doxycycline (for adults only) 2

Treatment Duration

• 7-10 days for most cases 2
• Some cephalosporins (cefuroxime-axetil, cefpodoxime-proxetil) have shown effectiveness with 5-day courses 2

Second-Line Treatment (for treatment failures)

• For patients not improving after 72 hours on initial therapy: 2
  • If started on amoxicillin: switch to high-dose amoxicillin-clavulanate 2
  • Consider respiratory fluoroquinolones (levofloxacin, moxifloxacin) for treatment failures or complicated cases (frontal, ethmoidal, or sphenoidal sinusitis) 2, 3

Common Pitfalls and Caveats

• Antibiotics should be reserved for true bacterial sinusitis, not viral upper respiratory infections 2, 1
• Bacterial sinusitis is typically diagnosed when symptoms persist without improvement for ≥10 days or worsen after 5-7 days 2, 4
• Recent studies show mixed results regarding the benefit of high-dose vs. standard-dose amoxicillin-clavulanate, with one study showing no significant difference in efficacy but increased side effects 5, 6
• Fluoroquinolones should be reserved for treatment failures or complicated cases due to concerns about antimicrobial resistance 2
• Adjunctive treatments like nasal corticosteroids may be helpful but have not been definitively proven effective 2

Microbiology Considerations

• The predominant pathogens in acute bacterial sinusitis are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 7
• Local resistance patterns should guide empiric therapy choices 2, 1