Treatment of Sinus Infections
For acute bacterial sinusitis, amoxicillin-clavulanate is the recommended first-line antibiotic treatment, with intranasal corticosteroids as an important adjunctive therapy. 1
Diagnosis and Classification
- Acute sinusitis is defined as symptoms lasting less than 4 weeks 1
- Bacterial sinusitis is likely when symptoms persist beyond 7-10 days or include severe symptoms with high fever and purulent nasal discharge 2
- The most common type is maxillary sinusitis, but frontal, ethmoidal, and sphenoidal sinusitis can also occur 3
First-Line Antibiotic Treatment
- Amoxicillin-clavulanate is recommended as first-line therapy for most patients with acute bacterial sinusitis 1
- Standard adult dosing is 875 mg twice daily for more severe infections 1
- For maxillary sinusitis, amoxicillin-clavulanate, second and third generation cephalosporins (except cefixime) are appropriate options 3
- Duration of antibiotic treatment is typically 10-14 days for acute disease 1
- Alternative 3-day regimens using azithromycin 500 mg daily for 3 days may be considered for uncomplicated cases 4
Alternative First-Line Options for Penicillin-Allergic Patients
- For patients allergic to penicillin, cephalosporins are recommended: 1
- Cefuroxime-axetil
- Cefpodoxime-proxetil
- Cefotiam-hexetil
- Pristinamycin is another option for patients with allergy to beta-lactams 3
- Clarithromycin (1 gram once daily for 14 days) can be used for acute maxillary sinusitis in penicillin-allergic patients 5
Treatment Based on Sinusitis Type
- For frontal, ethmoidal, or sphenoidal sinusitis, fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) should be considered due to higher risk of complications 3, 1
- These types of sinusitis require more aggressive treatment as they have higher risk of complications 3
Adjunctive Therapies
- Intranasal corticosteroids are strongly recommended as an adjunct to antibiotic therapy in both acute and chronic sinusitis 1, 2
- Saline irrigation helps prevent crusting of secretions and facilitates mechanical removal of mucus 2
- For cough associated with sinusitis (Upper Airway Cough Syndrome), first-generation antihistamine/decongestant combinations may be helpful 2
- Nasal decongestants can be used short-term (no more than 5 days) to reduce congestion 3, 6
- Adequate hydration, analgesics, and warm facial packs can provide symptomatic relief 1
Treatment Failure Protocol
- If no improvement after 3-5 days of treatment, switch to a different antibiotic 1
- For partial response, continue antibiotic treatment for another 10-14 days or consider second-line options 1
- Consider short-term oral corticosteroids for patients with marked mucosal edema or who fail to respond to initial treatment 1
Special Considerations
- Complete the full course of antibiotics even after symptoms improve to prevent relapse 1
- For recurrent sinusitis (≥3 episodes per year), evaluate for underlying inflammation, allergy, immunodeficiency, and anatomic abnormalities 1
- Antihistamines may be beneficial in patients with underlying allergic rhinitis 1, 6
When to Refer to a Specialist
- Refer patients with sinusitis refractory to usual antibiotic treatment 1, 2
- Recurrent sinusitis or sinusitis associated with unusual opportunistic infections require specialist evaluation 1
- Clinical signs suggestive of complicated sinusitis (meningeal syndrome, exophthalmos, palpebral edema, ocular mobility disorders, severe pain) require hospitalization and parenteral antibiotic therapy 3
Common Pitfalls to Avoid
- Overdiagnosis and overtreatment of acute sinusitis is common; most cases are viral and resolve without antibiotics 7
- Antibiotics should be reserved for symptoms lasting more than 7-10 days or severe symptoms with high fever and purulent discharge 2, 7
- Avoid using fluoroquinolones as first-line therapy for uncomplicated maxillary sinusitis to prevent development of resistance 3
- Avoid prolonged use of nasal decongestants (beyond 5 days) as this can lead to rebound congestion 6